Consent to Treat a Minor Child's Name * First Name Last Name Child's Nickname: Child's Date of Birth: MM DD YYYY Child's Sex/Gender: Child’s primary address: Address 1 Address 2 City State/Province Zip/Postal Code Country Please list any medications prescribed for minor: Name of Doctor: Last Seen: MM DD YYYY Name of Psychiatrist: Last Seen: MM DD YYYY List any head injuries, past or present major illnesses or allergies: School and Grade IEP or Special Ed? No Yes Father's Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Mother's Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Guardian's Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country In Case of Emergency Contact Their Relationship Phone (###) ### #### Please check all boxes that apply to minor and family: Divorce Legal Separation Custody Guardianship Restraining Orders Current Litigation Issues Probation Any issues concerning Divorce, Custody, Guardianship, Restraining Orders and/or Probation will require all documents to be presented on first visit to verify any legal issues and/or custody of child. Copies of these documents will be kept with minor’s records. I authorize Raduca Kaplan, LMFT, to provide psychotherapy to said minor. I also agree to be legally responsible for any changes said minor might incur during therapy with Raduca Kaplan, LMFT. * I authorize I do not authorize Date * MM DD YYYY Thank you!
