Parental Consent Form

All parents must complete the parental consent form for children/young person’s partaking in the service, before counselling can commence.

YOUNG PERSON’S DETAILS:

First Name *

Surname *

Date Of Birth: *//

Age:

Telephone: *

Address: *

Post code: *

Email *

PARENT/GUARDIAN DETAILS:

First Name: *

Surname: *

Relationship to him/her: *

Address: *

Email Address: *

Post Code: *

Home phone number:

Other Contact number: *

I Agree to the Consent Statement Below

I have read and understood the information given to me regarding the services You and Me
Counselling provides. I understand that if I have further enquiries, I can discuss them with the staff.
I understand that while the young person named above is working with You and Me Counselling,
he/she will be subject to the service’s code and conduct of behaviour and will be required to
conform with the instructions and guidance of the service.

PARENTAL CONSENT FORM

YOUNG PERSON’S DETAILS:

PARENT/GUARDIAN DETAILS:

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