Consent for Evaluaon/Treatment
I consent, for the purpose of Evaluaon and/or Treatment received from
_______________________ (therapist), you and the child will be working with a professional who is
legally and ethically responsible to keep all gathered informaon con!denal. I the parent/Guardian
give consent to use or disclose my child’s protected health informaon for the purpose of analyzing,
diagnosing, or providing treatment to my child and obtaining payment for my health care bills or to
conduct health care operaons. I understand that analysis, diagnosis or treatment of my child by the
therapist may be condioned upon my consent as evidenced by my signature below.
I understand I have the right to request a restricon as to how my child’s protected health
informaon is used or disclosed to carry out treatment, payment or healthcare operaons of the
pracce. I have the right to revoke this consent at any me. I have been provided and read a copy of
the Noce of Privacy Pracces. Any concerns regarding the therapist you can reach The Grievance
Board at 1525 Sherman St. Denver, CO 80203, phone (303) 866-3248.
I the Parent/Guardian give consent for the evaluaon/treatment with:
Therapist: __________________________
_______________________________
Child’s Name
_______________________________ _______________________________
Parent/Guardian Name (Print) Relaonship to Child
_______________________________ _______________________________
Parent/Guardian Signature Date