Counseling SB Consent Minor

Student's Name

Student's Date of Birth

Parent or Guardian Name

By initialing here, I hereby give permission to Counseling Services staff at New York Film Academy to provide my son or daughter psychotherapy while he/she/they are enrolled at NYFA.

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Address

Emergency Contact State

Emergency Contact Zip Code

Emergency Contact Home Phone

Emergency Contact Mobile Phone

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