Anne-Sophie Houdek, LCSW
Licensed Clinical Social Worker
5327 N.E. Glisan Street
Portland, Oregon 97213
CONSENT TO TREAT A MINOR
Being the parent or legal guardian of _________________________________(minor child’s printed name)
I, _______________________________(parent/guardian printed name) hereby give consent for Anne-Sophie Houdek, LCSW, licensed clinical social worker, to treat my minor child for the purpose of mental health stabilization.
Minor child’s date of birth:
Signature of parent/guardian:
Date:
