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You can print this form, fill it out, and mail the signed hardcopy to the address below, or have your child bring it to his/her first appointment.

Melanie Fuscaldo LPC, NCC
1935 Pauline, Suite 200
Ann Arbor, Michigan 48103
(734) 788-7806

Parental Consent Form

I ___________________________________________________________ give my consent for my

child ________________________________________________________ to engage in counseling
with Melanie Fuscaldo LPC, NCC.

I have read and agree to be bound by the Professional Disclosure Statement and
Agreement for Counseling forms of Melanie Fuscaldo.

Parent Signature _______________________________________________________

Date _______________________________

Parent name printed ____________________________________________________

Address ____________________________________________________________

Phone number _______________________________________________________

Email ______________________________________________________________