Permission For School-Based Services: Santa Fe & Rio Arriba

FOR SANTA FE AND RIO ARRIBA COUNTIES ONLY. Intake forms are securely encrypted and HIPAA compliant.

  • Permission For School-Based Services: Santa Fe, Rio Arriba
    ID #
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  • Permission For School-Based Services
  • I give permission for my child, to be in treatment with Southwest Family Guidance Center and Institute (SWFGC). I understand that this treatment may be done at the office of SWFGC and/or at my child’s school site.

    By requesting school-based therapy, I agree to initiate monthly contact with my child’s therapist and understand that if I am requested by the therapist to meet or return phone calls it is my responsibility to follow through with my child’s therapist’s request. If I am unable to follow through with the therapist’s requests, my child may be discharged from therapy services. I understand that my participation in my child’s therapy is crucial to the improvement of my child’s well-being.

    I understand that any co-pays or other charges related to the services provided are due and payable to SWFGC.

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