Permission For School-Based Services: Bernalillo, Sandoval & Valencia County - Southwest Family Guidance Center & Institute

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