Consent To Treat Minor – Greenwich Medical Partners

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(203) 661-2596
(203) 625-8331
644 West Putnam Avenue Suite 203
Mon-Fri: 8:00 - 5:00

(203) 661-2596
(203) 625-8331
644 West Putnam Avenue Suite 203
Mon-Fri: 8:00 - 5:00

Consent To Treatment

Child/Minor

Name of Child Patient

Rebecca Stiritz, Psy.D. and I have discussed my child’s situation. I have been informed of the risks and benefits of different treatment choices. I have had the chance to discuss these issues, have had my questions answered, and believe I understand the treatment that is planned. Therefore, I agree to play an active role in this treatment as needed, and I give this therapist (or another professional, if recommended) permission to begin this treatment.

Signature of Parent

Today's Date

Signature of Parent 2

Today's Date