Healthcare Child Services Form

HEALTHCARE CHILD SERVICES FORM

Child / Patient Information

Date of Birth:    Sex/Gender: Male Female Other

Parent / Legal Guardian Information

Emergency Contact

Insurance / Billing Information

Presenting Concerns & Services Requested

Please check all services requested or authorized for this child:

Primary medical care
Behavioral health evaluation / therapy
Developmental evaluation
Occupational therapy
Speech-language therapy
Medication evaluation / management
Laboratory testing
Immunization administration
Other:

Medical History

Immunization status: Up to date    Last known immunization date:

Developmental / Behavioral History

Has the child received prior behavioral or developmental services? Yes No    If yes, provider/agency:

Consent for Assessment, Treatment and Services

I, the undersigned parent or legal guardian, authorize the licensed clinicians and authorized staff of this practice to provide assessment, evaluation, testing, treatment, and related services for the child named herein. I understand that services may include direct clinical care, screenings, therapy, medication management, and coordination with other providers as necessary for treatment planning.

I understand that all treatments carry potential benefits and risks. Known risks, where applicable, have been explained and may include but are not limited to discomfort, temporary increase in symptoms, allergic reaction to medications or vaccines, or unforeseen adverse events. Benefits may include symptom reduction, improved functioning, and diagnostic clarification. Alternatives to the proposed services have been explained to me upon request.

I acknowledge that I may revoke this consent at any time in writing, except to the extent that clinicians have already relied on this consent for treatment or disclosures. Revocation does not affect actions taken prior to receipt of the revocation.

Authorization expiration (enter a date or write 'indefinite'):

HIPAA Acknowledgment & Authorization to Release Protected Health Information

I acknowledge receipt of the practice's Notice of Privacy Practices describing how my child's health information may be used and disclosed. By signing below I authorize the release of relevant protected health information to other providers, schools, insurance carriers, or agencies as necessary for treatment, payment and program operations, limited to the minimum necessary information.

I authorize release of information to:    Purpose:

Specific information to be released (check all that apply):
Medical records
Behavioral / mental health records
Educational / school records
Immunization records
Other:

Authorization expiration for release (enter date or 'upon completion of care' or 'indefinite'):

Additional Authorizations

Telehealth: I authorize the provision of services via telehealth where appropriate, understanding that telehealth has benefits and limitations and that privacy risks may exist. Authorized

Photographs / Video: I authorize the use of photographs or video of the child for clinical records only. For use beyond clinical records, a separate consent will be required.
I authorize photographs/video for clinical record use

Certifications & Acknowledgments

By signing below, I certify that I am the parent or legal guardian of the child named above, that I have the authority to consent to the services described herein, and that the information provided on this form is true and complete to the best of my knowledge. I acknowledge that I have had an opportunity to ask questions about services, risks, and alternatives and that my questions have been answered to my satisfaction.

I understand that billing or insurance claims may be submitted for services provided and that I am financially responsible for any charges not covered or paid by insurance unless otherwise agreed.

Patient assent (for children of applicable age): Assent obtained    If applicable, patient printed name:

Sign Now