Supervisor selection

By this I, ,
I, the undersigned, confirm my agreement to the individual diagnostic and correctional work of a psychologist who conducts practical activities, chosen by me at my own discretion and under my personal responsibility, with the child for whom I order the appropriate service.
I confirm that I am indeed one of the child's parents or a member of his family, or his legal representative, and agree to work closely with a psychologist.
In addition, I understand that I am solely responsible for the possible unforeseen consequences of the child's perception of information obtained in the process of working with a psychologist, and I am informed that I have the right to withdraw the above consent at any time.