Alba Wellness, Inc.
Counseling – Transformation – Empowerment
433 Kitty Hawk Rd. Suite 219 Universal City, TX 78148 Phone (210 ) 566-1280 | Toll Free (855) 566-ALBA | Fax (210) 566-1289
Consent to Treat a Minor
I, as the parent and/or legal guardian for
the minor childgive my consent for said
child to receive counseling from a representative of Alba Wellness Incorporated. I
understand that I may withdraw this consent at any time. I will first notify
a representative of Alba Wellness Incorporated by telephone and then in writing, if and
when I choose to withdraw this consent.
Child’s Information: (Name)
By signing below, I agree that the above information is accurate to the best of my