Consent For Treatment of a Minor Child "*" indicates required fields Step 1 of 2 50% The following statements provide your legal consent to and financial responsibility for counseling services to a minor child. These statements are important to protect the child, the parent/guardian/conservator, and the therapist. Please carefully review this information and sign where indicated. You are requested to discuss any question you may have with the therapist.Name of Whom is Authorizing (Parent's Name):* First Last I am the:* Biological Parent Adoptive Parent Legal Guardian Name of Minor Child:* First Last I am legally responsible for the child named above and grant permission to Rachel Koppa, Ph.D., LPC-S, LMFT to conduct therapy with this child. I accept responsibility for the payment at the time of service to Koppa Counseling, PLLC for services provided to this child.* I Accept Please enter your full name in the text box below to grant permission to Rachel Koppa, Ph.D., LPC-S, LMFT to conduct therapy with this child.* * I understand that by typing my name and clicking on "Submit", I am electronically signing this document. DUTY TO WARN NOTICERachel Koppa, Ph.D., LPC-S, LMFT, is committed to the confidentiality and privileged communication with all clients. There are, however, several exceptions. According to state law, any evidence of child abuse must be reported to the authorities. If any individual intends to take harmful, dangerous, or criminal action against another individual, or against himself/herself, it may be the therapist’s duty to report such action or intent.* I Accept Please enter your full name in the text box below to accept the policy.* * I understand that by typing my name and clicking on "Submit", I am electronically signing this document. CHILD-ADOLESCENT INTAKE"*" Indicates required fields "+" Click to Add a New Line Child's Full Name:* First Middle Last Nickname: Child's Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child's Phone:Child's Date of Birth* Child's Email (if applicable) PARENT(S) INFORMATIONParent(s) Names or Primary Guardian info:*Name:Cell Number:Other Number:Email: Add RemoveIn case of emergency, whom may I contact on your behalf?Name:* Phone Number:*Relationship:* EDUCATIONAL HISTORYWhat school does your child\teen attend:* Current Grade: Has your child\teen ever repeated a grade?* Yes No If so which one(s):* Favorite Subject: Least Favorite Subject: Does your child\teen receive any special education services?* Yes No If yes, which service? Does your child\teen receive tutoring?* Yes No Is your child\teen in a gifted/talented/honors program?* Yes No Does your child\teen like school?* Yes No Has your child\teen experienced any of the following at school?Please check all that apply. Fighting Suspension Lack of friends Gang influence Learning disabilities Incomplete homework Drug/alcohol Poor attendance, Behavior problems Detention Poor grades Has your child\teen been the victim of bullying or bullied other children?* Yes No If yes, please describe:*MEDICAL HISTORYPediatrician’s Name:* Phone:Is child\teen under the care of another medical specialist?* Yes No If Yes, type of specialist:* Specialist Phone:*Please list any chronic illness, disabilities, medical conditions that your child\teen has been diagnosed with:Illness/Diagnosis:Dates: Add RemoveList all medications that your child\teen is currently taking:Medication:Dosage:Treating: Add RemoveTherapy / Psychiatric ExperienceIs your child\teen currently seeing another therapist?* Yes No If yes, who is your child\teen seeing?* Has your child\teen ever been in therapy in the past?* Yes No If yes, please fill out the following on your previous counseling experience(s)*Therapist:Location:Dates:Reason: Add RemoveHas your child\teen ever been hospitalized for psychiatric reasons?* Yes No If yes describe briefly and indicate dates and circumstances*Is your child\teen under the care of a psychiatrist?* Yes No Please complete the Bilateral Authorization to Exchange Professional Information with this professional. If yes, enter the following:*Psychiatrist namePhoneAddressPsychiatrist Name* Phone*Address Street Address City State / Province / Region ZIP / Postal Code OTHER HISTORYHas your child\teen ever experienced any type of abuse (physical, sexual, or emotional)?* Yes No If yes, please describe:*Has your child\teen ever made a statement of wanting to harm themselves or seriously harm someone else?* Yes No Has your child/teen purposely harm themselves or another?* Yes No If yes, to either question please describe the situation:*Has your child\teen ever experienced any serious emotional losses (such as a death of or physical separation from a parent or other caretaker)?* Yes No If yes, please explain:*Are there any behaviors that your child\teen currently does too often, too much, or at the wrong times that gets them into trouble?* Yes No If yes, please describe:*Are there any behaviors that your child\teen fails to do, as often as you would like or when you would like?Please list positive strengths of your child\teen: (What do you like about your them? What do others like about your them?)*How would you describe your their self-esteem?*Briefly describe the reason(s) for seeking help at this time?*What goals do you wish to accomplish during the therapy process as a parent?*What goals does your child\teen wish to accomplish during the therapy process? (can be different than parent’s response)*FAMILY HISTORYMother's Name:* First Last Mother's Occupation: Father's Name:* First Last Father's Occupation: Who does your child\teen currently live with?*Names:Age:Relationship to child\teen:Grade/Job: Add RemoveWho are your child’s significant others NOT living with your child?Names:Age:Relationship to child\teen:Grade/Job: Add RemoveAre child\teen’s parents’?* Married Separated Divorced Windowed If parents divorced/separated please list dates:Who in the family is your child\teen closest too?*What are some of the strengths of your family?*Does anyone in the child\teen’s family use currently (or in the past) any type of drug, tobacco, or alcohol?* Yes No If yes please describe:*Has anyone in your child\teen’s family been diagnosed with a psychiatric illness (depression, anxiety, eating disorder, etc.)?Is there anything else that you think would be important for Dr. Koppa to know about your child\teen, you, or your family?Who referred you? May I thank him/her? Yes No