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Parental Consent Form

 

I ____________________________________________________ give my

consent for my child:___________________________________________

to engage in counseling with Dr. Betty Carvajal, Ph.D., LMHC
and Psychotherapy Bilingual Solutions, LLC.


Parent(s) Signature(s): 

___________________________________________________________ 

Parent Name Printed:

___________________________________________________________

Address: _________________________________________________

Zip Code: _____________ City________________State____________

Phone Number: _______________________

Cell/Alternate Number: __________________
 

Email: _______________________________