Document generator

Child therapy consent

Enter the details, download a PDF ready to sign and sign it in the mObywatel app or with a trusted signature. The data never leaves your browser.

The document is created entirely in your browser. Names and PESEL numbers are not sent to our server or stored anywhere.

Parent or legal guardian 1

Full name *

PESEL or ID document number *

PESEL is checked locally (checksum only). Instead of PESEL you can enter the series and number of an ID card or passport.

Date *

Parent or legal guardian 2

Optional. If left blank, the document will have space to fill in by hand.

Full name

PESEL or ID document number

PESEL is checked locally (checksum only). Instead of PESEL you can enter the series and number of an ID card or passport.

Date

Child

Child's full name *

Child's date of birth (optional)

Town

Printed next to the date in the document header.

Scope of consent

Tick what you consent to. You can select several options.

Psychological consultationPsychological assessmentPsychological therapy

Consent of a child over 16

A psychologist working with a person aged 16 or over also needs that person's consent. Tick to add a second page with the child's statement.

The child is 16 or older and will sign their own statement

Prefer to fill it in by hand? Download the blank form (PDF)

How to sign the document electronically

The easiest way is to sign the downloaded PDF in the mObywatel app, with no printing or scanning. When two parents sign, each signs the same file in turn. Below are three methods, starting with the simplest.

Recommended

Qualified signature in the mObywatel app

You need: a phone with NFC, an active mDowód in the mObywatel app and a plastic Polish e-ID card issued after 4 March 2019. The service is free for up to 5 signatures a month and the PDF may be at most 5 MB.

Open the mObywatel app, go to Sprawy urzędowe (Official matters) and choose Podpis kwalifikowany (Qualified signature).
Choose a signature provider (e.g. Cencert, SimplySign, Sigillum or mSzafir), accept the terms and confirm the data from your mDowód.
Turn on NFC, enter the 6-digit CAN number from the front of your ID card and hold the e-ID against the back of the phone until the app creates the certificate.
Select the downloaded consent file (PDF) and confirm the signing.
Save the signed file on your phone straight away, because the app does not keep it.
The second parent repeats the steps on their own phone, signing the already signed file.

The Podpisz dokument (Sign a document) feature in mObywatel (personal signature, PIN 2) is a different type of signature, meant mainly for dealing with public offices. For the consent choose Podpis kwalifikowany. The same signature is also available in a browser at podpis.mobywatel.gov.pl.

Instructions on the mObywatel website ↗

Trusted signature (podpis zaufany) on gov.pl

You need a trusted profile (profil zaufany). If you do not have one, you can set it up through online banking in a few minutes.

Open the gov.pl page Podpisz dokument elektronicznie and choose Podpisz lub sprawdź dokument PDF.
Add the downloaded consent file and click Podpisz.
Log in through login.gov.pl: with your bank, with a login and password, or with a QR code in the mObywatel app.
Choose Podpisz podpisem zaufanym, enter the code from the text message and place the signature mark in the parent's signature field.
Download the signed document. The second parent logs in to their own account and signs the same file.

The trusted signature mark stays visible in the document, so place it in the Data i czytelny podpis field of the right parent.

Open signing on gov.pl ↗

Print and sign by hand

Print the PDF and sign it legibly in the fields for parents (and for the child, if they are 16 or older).
Bring the original to the first visit or send us a clear scan or photo.

The psychologist completes their part of the document during the visit.

What to do with the signed document

Send the signed PDF to kontakt@sztukaharmonii.pl. Put the child's full name in the subject line. You can also show the document at the first visit. Do not send us scans of ID cards, the signed form alone is enough.

How to check that the signature worked

Open the file in Adobe Acrobat Reader: a bar above the document will say that the document is signed and all signatures are valid. A trusted signature can also be checked on the same gov.pl page under Sprawdź dokument.

Important

A qualified signature has the same legal effect as a handwritten one. The trusted signature and the personal signature have that effect by statute when dealing with public administration, and elsewhere they work with the recipient's agreement. At Sztuka Harmonii we accept all three forms as equal to a handwritten signature.

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