Consent to Treat - Minor

Please read thoroughly answering all questions and sign to provide your consent for treatment. Click 'submit' when done.

I provide my permission for my minor child to participate in outpatient therapy services with therapist Lesa J. Fischer, LCSW at Madison Mental Health Services.

Yes

I understand that all services with therapist Lesa J. Fischer, LCSW and Madison Mental Health Services are voluntary. I understand that I have the right to refuse any aspect of treatment for my minor child at anty time.

Yes

I understand that I have the right to be informed by my minor child's therapist about: a) the benefits, side effects and administration of treatment; and b) the consequences of not receiving the proposed treatment.

Yes

I understand that therapy is based on a trusting relationship between therapist and client, thus the therapist will keep information shared by the client confidential except in certain situations in which ethical responsibility limits this. You will be notified if: a) child reveals information about hurting themself or another person; b) child or another person may be in physical danger.

Yes

This consent will be effective until treatment is terminated or you exercise your right to withdraw. By signing this form, you give your informed consent for your minor child to participate in outpatient therapy services.

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete.

This consent will be on file throughout the time that your child participates in outpatient therapy with therapist Lesa J. Fischer, LCSW at Madison Mental Health Services. You may revoke this consent at any time.

Thanks for submitting!

Lesa J Fischer, LCSW

Offering help to navigate life's challenges

702 North Blackhawk Avenue
Suite 104
Madison, WI 53705

(608) 444-7432

lesa.fischer@charter.net

Consent to Treat - Minor