8700 South Kyrene Road l Tempe, Arizona 85284

I have been informed of the counseling services, both group and individual, that may be provided by the psychologist. I grant my permission for ____________________________(Child's Name) to participate in this program. I understand that some test may be administered, to aid in the counseling process.

 _______________________________(date)

____________________________________(Parent or Guardian)

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I do not wish my child to receive counseling services from the psychologist.

 _______________________________(date)

____________________________________(Parent or Guardian)