Legal Guardian *

*By typing in my name and or initials below, I acknowledge that it is taking the place of my handwritten signature.

First Name

Last Name

I, the Legal Gaurdian, give permission for Dr. Dodd, to work with (Minor Child) *

Yes

Name of Minor *

First Name

Last Name

in the role of counselor/therapist at Level Ground Christian Counseling. I have been provided the informed consent and agree to the conditions contained therein. *

Yes

No

Date

MM

DD

YYYY