CHILD AND ADOLESCENT CONTACT FORM Jennifer

CHILD AND ADOLESCENT CONTACT FORM
Child's Name
Birth Date

MonthDayYear
Age
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone (if applicable)
Email (if applicable)
example@example.com
Reason for Referral
Referred By
Parent/Guardian #1
Home Phone
Cell phone
Email
example@example.com
Address, if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2
Home Phone
Cell phone
Email
example@example.com
Address, if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School
Grade
School Contact(s)
Phone
Emails
Emergency Contact
Relationship to child
Primary phone
Secondary phone
Policies and Procedures: I was provided with the Child Development Associates “Policies and Procedures” document, and I was given the opportunity to read and ask questions about the content of the document, including the relevant sections on fees, payments and teletherapy. My signature below indicates my informed and willful consent to these policies, and to my child and family’s treatment with CDA.
Parent Name
Parent Signature

Clear
Date

MonthDayYear
Date
Telehealth, E-mail, and SMS communication disclosure: It is important to be aware that electronic communications can be relatively easily accessed, and hence can compromise the privacy and confidentiality of such communication. I understand that the transmission of my medical information could be interrupted or distorted by technical failures, or accessed by unauthorized persons.
Parent Name
Signature

Clear
Date

MonthDayYear
Date
6 Palmer Avenue | Scarsdale, NY 10583 | 914-723-2228
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