Child Treatment Consent Form.

Child Treatment Consent Form.

Delaware Behavioral Health, Inc.
Name of Child

First NameLast Name
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Age
Gender

MaleFemale
Parents
Status of Parents

MarriedLiving Together (not married)SeparatedDivorcedOther
Custody Arrangement

Joint CustodySole CustodyNo Custody ArrangementGuardianshipOther
Name of Father

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Mother

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Same address as above

Yes
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize the Clinic to conduct an assessment and/or treatment to our child, {nameOf}.
Signature
Name

First NameLast Name
Signature
Name

First NameLast Name
Should be Empty:

Parents