Permission For School-Based Services FOR BERNALILLO, SANDOVAL & VALENCIA COUNTY ONLY. Intake forms are securely encrypted and HIPAA compliant. Permission For School-Based Services ID # CLIENT FIRST NAME* CLIENT LAST NAME* DOB* MM slash DD slash YYYY Permission For School-Based Services EMAIL* SCHOOL NAME* 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.GUARDIAN NAME* RELATION TO CLIENT* DATE* MM slash DD slash YYYY
