Language
English (US)
Español
Child Treatment Consent Form.
Delaware Behavioral Health, Inc.
Name of Child
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Parents
Status of Parents
Married
Living Together (not married)
Separated
Divorced
Other
Custody Arrangement
Joint Custody
Sole Custody
No Custody Arrangement
Guardianship
Other
Name of Father
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Mother
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Same address as above
Yes
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I hereby authorize the Clinic to conduct an assessment and/or treatment to our child, {nameOf}.
Signature
Name
First Name
Last Name
Signature
Name
First Name
Last Name
Submit
Should be Empty: