ACT for Today

Affiliation of Catholic Therapists

Dr. Paul C. Seishas

Marriage and Family Therapist MFT #25829

Adjunct Professor, University of San Francisco

Educational Consultant

Spiritual Director

ACT for Today Affiliation of Catholic Therapists
9961 Elk Grove Florin Road
Elk Grove, CA 95624
ph: 916-616-1800
paul.seishas@gmail.com

Form-Release Consent to Treat Minor

*I, (enter name in box)

*as the parent/legal guardian and holder of privilege for:
(enter minor's name in box)

*give my consent for Dr. Paul C. Seishas to conduct psychotherapy with:(Enter minor's name in box)

I have been notified that all material discussed during the psychotherapy sessions is confidential and can be released only with the permission of the holder of the privilege. I have been informed of the limitation to confidentiality in the Office Policies form, which I have read and signed.

In case of a minor, special sensitivity may be required in releasing information about certain topics such as drugs and sex. I will accept Dr. Seishas’ judgment in regard to releasing or sharing information obtained during the course of psychotherapy with the
minor that may endanger or jeopardize the patient's well being.

*Name:

*Relationship:

Name:

Relationship:

Date:

Clicking Submit is accepted as an electronic signature to this form.

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ACT for Today Affiliation of Catholic Therapists
9961 Elk Grove Florin Road
Elk Grove, CA 95624
ph: 916-616-1800
paul.seishas@gmail.com