Authorization To Treat Minor Child

Whiting & Associates, LLC.

Jerri L. Whiting, Ph.D., Jennifer Lowe, LCSW

632 SE 4TH Street

Lee’s Summit, MO 64063

Phone (816) 554-7750 , Fax (816) 554-7866

drjewhiting@gmail.com

I warrant that I am a custodial parent of the above named minor child.  I hereby give my permission for him/her to receive counseling from Jerri L. Whiting, Ph.D or Jennifer Lowe, LCSW.  I acknowledge that I am aware of the mandating reporting laws in the State of Missouri.  I am also aware that I can withdraw the permission to treat my child at any time.  I will assume responsibility for notifying that child’s other parent that counseling has been initiated and will take responsibility for arranging for the payment of all counseling services for my child.

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