Paul D. Murdock Psy.D. Counseling Services
9700 El Camino Real, Suite 303
Atascadero, CA 93422
Ph: 805-305-4072

Consent to Treatment of a Minor 

Name of child client: _______________________________________

The therapist named below and I have discussed my child’s situation. I have been informed of the risks and benefits of several different treatment choices. The treatment chosen includes these actions and methods: 
_______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 

These actions and methods are for the purposes of: 
_______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 

I have had the chance to discuss all of 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 permission to begin this treatment, as shown by my signature below. I am also the legal custodian of this child, and there are no court orders in effect that would prohibit me from consenting to the treatment of this child.

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Signature of parent/guardian												Date 

I, Paul D. Murdock Psy.D, have discussed the issues above with the child’s parent or guardian. My observations of this person’s behavior and responses give me no reason, in my professional judgment, to believe that this person is not fully competent to give informed and willing consent to the child’s treatment. 

_____________________________________________________	_________________
Paul D. Murdock Psy.D.													Date 

❑ Copy accepted by parent/guardian 	❑ Copy kept by therapist 

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.