Counselor______
Opened _______
Phone: 772-403-4530
Fax: 772-403-4513
Application and Consent for Youth Counseling Services
CSC # ________
Agency # ______
Parent/Guardian Name ___________________________________ Relationship to Child: ____________
*Information needed strictly for grant statistics, optional.
Household information:* Dual parent
Single parent
No. in household
Household Income:*  0.00 - 9999.00
 10000.00 - 19999.00
 20000.00 - 29999.00
 30000.00 - 39999.00
 40000.00 - 49999.00
 50000.00 - and up
Race*
Social Security Number*: _______ - _____ - _______ DOB*: ___________
Ethnicity*: WhiteMulti-ethnicAfro-AmericanAsianNative AmericanHispanic Other 
If dual custody applies, guardian name and contact information (attempts will be made to keep both parties
informed):____________________________________________________________________________
Address ______________________________________________________________________
Street and Apartment Number
_____________________________________________________________________________
City/State/Zip Code
Phone (H) _______________________ (W) ______________________ (C) ______________________
E-mail Address: ______________________________________________________________________
Name of Loved One
Relationship to child _______________ Treasure Coast Hospice
Patient? YES
NO
Child Name
Age
D.O.B.
Social Security Number*
School & Grade
Sex
Race
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I hereby give full consent for my child(ren) to receive counseling and support. In addition, I give my consent for Treasure Coast
Hospice Counseling Services counselor to have communication with my child’s school guidance counselor, teacher, and/or therapist
regarding my child’s progress.
I also give my consent for any group photographs or videos of my child that may be taken during participation in our services, and
the display of their artwork or writing for the purposes of increasing awareness of Hospice programs. I understand that only the
first name of my child would be used in connection with any photos or artwork if used in publications such as the Hospice
newsletter or program brochures. This consent is valid two years from date of signature. All information provided will be held
confidential.
*The information provided here may be used by the funders of this program for research purposes or to evaluate the program’s
effectiveness.
I understand that copies of THE YOUTH PROGRAM DESCRIPTION OF SERVICES and the NOTICE
REGARDING PRIVACY OF PERSONAL HEALTH INFORMATION are available to me at Treasure Coast Hospice
Counseling Services.
Treasure Coast Hospice Counseling Services is funded entirely by grants and donations. Your tax-deductible contributions make it
possible for us to continue providing quality, compassionate grief counseling in the Treasure Coast community.
________________________________________________
Parent/Guardian Signature
Form 125 – Revised 01/10
_________________
Date