Supplemental Information for Minors - Hands of Hope America

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Child’s name *

First

Last

Date of Birth: *

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* Is there a Parenting Plan? (Please provide a copy to LCS)

Yes
No

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Child lives with: *

Mother's Name *

First

Last

Child’s school grade: *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Phone *

Father's Name

First

Last

Messages ok? *

Yes
No

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Phone

Messages OK?

Yes
No

Other Parent(s) or Guardians (if applicable)

First

Last

Other Parent(s) or Guardians (if applicable)

First

Last

Partnership with Hands of Hope America: Please check one: *

I give my permission for Lutheran Counseling Services to consult with the faculty and staff at Hands of Hope America regarding my child.
I do not give my permission for Lutheran Counseling Services to consult with the faculty and staff at Hands of Hope America regarding my child.

Consent for treatment of Minors:

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I, *

do hereby authorize that my child, *

may receive mental health treatment provided within the Hands of Hope America Community Center. Counseling services are provided free of charge. I am aware that custodial parents and legal guardians must give consent before treatment begins. Parents may withdraw their child from counseling at any time. If parents are currently separated or divorced, both parents are required to give consent. If one parent has full legal right, LCS would need to be made aware with proper documentation (i.e. copy of divorce agreement) if the other parent does not have rights to access information regarding the child.

Print Name *

First

Last

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Parent/Legal Guardian Signature *

Today's Date *