Kids Form

Kids Therapy and Testing

Step 1 of 3


  • Please select the provider that you are scheduled to see.
  • MM slash DD slash YYYY
  • Parent Information

  • MM slash DD slash YYYY
  • Patient Information

  • MM slash DD slash YYYY
  • Developmental milestones

    At what age did your child master the following milestones? Please use the drop-down menus to answer.
  • Caregivers: Biological parents, step-parents, and any other significant adult providing care for the child
    NameRelationship to childOccupationHighest grade completed 
  • NameAgeRelationship to childHow well do this person and the child get along? 
  • Please indicate below if any of the child’s relatives (parent, brother, sister, aunt, cousin, etc.) have been treated for the following:
  • Include all mother’s pregnancies. Begin with the first and include miscarriages/ stillbirths.
    YearFather's last nameLength of pregnancyLength of laborProblems at birthAny physical, emotional, behavioral, or educational problems? 
  • Father’s children by other unions.
    YearFather's last nameLength of pregnancyLength of laborProblems at birthAny physical, emotional, behavioral, or educational problems? 
  • List all physicians and therapists your child has previously seen or is currently seeing.
    NameCityReason for visit 

    I understand there are risks, varying lengths and methods of treatment, as well as possible consequences of the decided treatment which typically includes, some, or many of the following methods and interventions: Stabilization, Decrease and relieve symptomatology, Improve coping, Skill development, Grief resolution, Stress management, Behavior modification, Medication management 1. While I expect benefits from this treatment I fully understand and accept that because of factors beyond ourcontrol, such benefits and desired outcomes cannot be guaranteed. 2. I understand that this mental health provider does not provide emergency service and I will be informed of whom/where to call in an emergency or during the evening or weekend hours. 3. I understand that regular attendance will produce the maximum possible benefits but that I am free to discontinue treatment at any time in accordance with office policies. 4. I understand that I am financially responsible for any portion of the fees not covered or reimbursed by my health insurance. 5. I have been informed and understand the limits of confidentiality, that by law, the therapist must report to appropriate authorities any suspected child abuse or serious threat of harm to myself or another person. 6. I am not aware of any reason why I should not proceed with therapy/treatment and I agree to participate fully and voluntarily. 7. If applicable, I am the custodial parent of a minor child. I hereby give the non-custodial parent, permission to seek treatment on our child’s behalf. The provider practices with an association of independently practicing professionals which share certain expenses and administrative functions under the name PCA Resources, Inc. While they share office space, this provider is a completely independent professional rendering clinical services and is fully responsible for those services. Clinical records are separately maintained and other professionals cannot have access to them without your specific written permission. If you have any questions regarding this policy, please discuss these with the provider as soon as possible. Your signature below indicates consent for psychological/psychiatric treatment and indicates that you have read the above statement and agree to the above terms. Your commitment to this process and your assistance in understanding these necessary policies are an important part of your care.

    Mental Health Providers have a legal obligation or duty to maintain the confidentiality of their communications with their patients. There are exceptions, however, to this right of confidentiality. These include the following: *You are a danger to yourself or others. *Child abuse is disclosed.*Elder abuse is disclosed.*You seek treatment to avoid detection or apprehension or enable anyone to commit a crime. *Your therapist was appointed by the courts to evaluate you. *Your contact with your therapist is for the purpose of determining sanity in a criminal proceeding. *Your contact is for the purpose of establishing your competence. *Your contact is one in which your therapist must file a report to a public employer or as to information required to be recorded in a public office, if such report or record is open to public inspection.*You are under the age of 16 years and are the victim of a crime.*You are a minor and your therapist reasonably suspects you are the victim of child abuse. *You are a person over the age of 65 and your therapist believes you are the victim of physical abuse. *If you are deceased and the communication is important to decide an issue concerning a deed or conveyance, will or other writing executed by you affecting interest in property. *You file suit against your therapist for breach of duty or your therapist files suit against you. *You have filed suit against anyone and have claimed mental/emotional damages as part of the suit. *You waive your rights to privilege or give consent to limited disclosure by your therapist.*Your insurance company paying for services has the right to review all records. If you have any questions about these limitations, please discuss them with your therapist. I am consenting to receiving outpatient mental health treatment and understand my legal right to confidence and the aforementioned exceptions.