Minor Intake Form: Mother Acknowledgment

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CONSENT FOR TREATMENT: PLEASE BE ADVISED THAT BOTH PARENTS MUST CONSENT TO THERAPY FOR A MINOR:

Minor Patient Name(Required)

First Last

Mother's Name(Required)

First Last

Mother's Email(Required)

Mother's Phone(Required)

Mother's Address(Required)

Street Address Address Line 2 City State ZIP Code

Date(Required)

Signature(Required)

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