Please print this form - right click on the form and select print.
Relate York & Harrogate
Relate Children & Young Person's Consent
Please complete this form if the young person is under 16 years. Please ensure that they have it with them when they attend their first appointment.
Name of the young person:
Date of birth:
Name of legally responsible adult:
Relationship to young person:
I give my consent to allow:
to see a Counsellor from Relate's Children and Young People's service (part of Relate York & Harrogate)
* I will be collecting the young person afterwards
* I will not be collecting the young person afterwards
* Please carefully consider the safety implications involved in the journey to and from counselling, before deleting as appropriate. Please state below how the young person will get to and from sessions.
Signed:
Telephone Number:
Date: