05 - Child Addendum

Child Intake Addendum and Consent

To be completed if the client is under the age of 18.
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Parent Name*
Full name of custodial parent.
Parent Name
Full name of custodial parent.
I {parentName} am the legal custodial parent of {childsName} and give my permission to Networks, Inc. to provide mental health services to my child.
We {parentName} and {parentName14} are the legal custodial parents of {childsName} and give our permission to Networks, Inc. to provide mental health services to our child.
Parent Signature*

Clear
Please draw your signature here to sign.
Additional Parent Signature

Clear
Please draw your signature here to sign.

	Yes	No	Describe
Medical problems during pregnancy?
Medications during pregnancy?
Did either parent drink much alcohol or use other drugs during pregnancy?
Other problems during pregnancy? (marital, job, money, living conditions)
Unusual birth weight?
Was child born premature?
Problems with newborn period or infancy? (Being born blue, birth defects, yellow jaundice, seizures, infections, injuries, feeding problems)
Past or present child allergies of any kind?
Is your child overactive?
Trouble paying attention?
Trouble staying focused on an activity?
Child fluctuates from happy to sad quickly with little apparent cause?
Easily frustrated?
Unpredictable emotional responses?
Slow to warm up to new situations or people?
Does your child react strongly to physical pain?
Does your child react strongly to other things?

	Yes	No	Describe
Has your child had learning problems?
Has your child had social problems in school?
Is your child receiving special help at school?
Any other school concerns?

Child Intake Addendum and Consent