CONSENT FOR SERVICES

I hereby authorize Thalia Ferenc, MSW, MA, CSW to provide the

following services

to _____________________________________________________
       (Child’s name)                         (Date of Birth)

Services to be provided may include: ASSESSMENT AND/OR OUTPATIENT COUNSELING.

These above services have been explained to me and I understand that my participation, and/or my child’s participation, in this program is voluntary.

____________________________               ___________________
Client or Guardian Signature                         Date

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