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Home
About Us
Programs
After school Program
Pre-K Program
Child and Family Therapy
Clubs
Writing Workshops
Digital Library
Mission & Vision
Blog/News
Gallery
Photos
Videos
Contact
After School Program | Studio City | Los Angeles | California
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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:
First Name
Last Name
Last Seen:
MM
DD
YYYY
Name of Psychiatrist:
First Name
Last Name
Last Seen:
MM
DD
YYYY
List any head injuries, past or present major illnesses or allergies:
IEP or Special Ed?
Yes
No
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.
Date completed this form
MM
DD
YYYY
Thank you for completing this form!
Consent Header
Consent to Treat a Minor Form
