Youth Mentorship Therapy Session Observation Consent Form
Please complete this form to provide consent for observation of a youth mentorship therapy session.
Youth Participant's Full Name
*
First Name
Last Name
Youth Participant's Age
*
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Observer's Full Name
*
First Name
Last Name
Observer's Affiliation or Organization
*
Date of Therapy Session to be Observed
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Purpose of Observation
*
Relationship of Observer to Youth (if any)
Please Select
No relationship
Mentor
Teacher
School Counselor
Other
Parent/Guardian Signature (Please sign below to confirm your consent)
*
Submit Consent
Submit Consent
Should be Empty: