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Child/Adolescent Patient Information
Please provide the following information and print clearly. In addition to this basic
information, your child’s developmental, social and educational history will be gathered.
Referred By:__________________________________________________________
Child’s full name:______________________________________________________
Birth date:________________________
Grade:_________________________
Home Address_________________________________________________________
_____________________________________________________________________
Home phone:_______________________
OK to call you here? Yes___No___
Mother’s full name
_____________________________
Work phone:__________________
Cell phone:___________________
O.K. to call you here? Yes___No___
Email Address:________________
Father’s full
name_____________________________
Work phone _______________
Cell phone_________________
O.K. to call you here? Yes___No___
Email Address:________________
At this time, who has legal custody of this child?_________________________
At this time, who has physical custody of this child?______________________
In case of emergency, the therapist has my permission to contact:___________
______________________________Phone___________________________
Relationship to child_______________________________________
Current medications and dose________________________________________
Who is the doctor that prescribed these medications?______________________
Does this child have any acute medical conditions, ones that pose an immediate threat to
his/her health? (severe allergies, asthma, other respiratory or cardiac difficulties, etc.?)
Yes___No___ If yes, please list here:
Please list any current or chronic medical conditions:
Date of last physical exam___________Name of primary care physician______________
Phone________________________________________
School currently attending:_______________________________Phone_____________
Homeroom teacher/advisor_____________
X.__________________________________ X.________________________________
Signature of parents and/or parent and/or guardian completing this form and date signed.
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Consent for Psychological Treatment of a Child/Adolescent
Welcome to my practice. This document contains important information about my
professional services and business policies. Please read it carefully and ask me to clarify
anything that you do not understand. When you sign this document, it will represent an
agreement between us.
I request that Lori Radner provide psychological assessment and/or treatment to
________________________ a minor child/adolescent for whom I am a legal guardian.
The therapist is a fully licensed psychologist. This form is to document any consent for
assessment/ treatment as well as an agreement to the conditions of the assessment and/or
treatment.
An assessment may consist of interviews with the parents, surveys, educational tests
and/or psychological tests. Areas to be assessed may include intellectual and academic
functioning, attention and concentration, psychological status and emotional state. I
understand that the results from this assessment and the written report will not be shared
with anyone unless I give permission for such a release of information.
I understand that the goal of treatment is to reduce distress, increase understanding of the
sources of difficulties, and/or increase the ability to function in life in adaptive ways. The
therapist’s approach to treatment is to use discussion to explore the patient’s thoughts,
feelings and difficulties. This is a collaborative effort and suggestions may be made to
alternative ways of understanding themselves to help make more adaptive choices. In
younger patients, play therapy may be utilized.
Most children find psychological assessment and/or treatment to be an interesting
experience as well as a means of learning more about themselves. It is generally thought
of as a benign procedure. However sometimes people can be disappointed or unsettled by
the results. In addition, any discussion of problems may bring about some emotional
strain or distress. I am welcome and encouraged to discuss any and all questions or
concerns that I have regarding the treatment and/or assessment. I understand that the
practice of psychological services is not an exact science and so predictions of its
benefits, outcomes or duration are not precise or guaranteed. There are many factors that
influence the outcome of treatment, which includes the commitment made by the parents.
I agree to be financially responsible for the entire cost of the treatment, which will be
billed to me. If my insurance does not cover mental health services, I will be expected to
pay for each session at the time it is held.
Checks should be made payable to Lori Radner. I understand that if I do not bring
payment to a session, I will be expected to bring both the past due and current payment to
the very next session. I understand that if I fall behind in payment by more than two
sessions, services may be suspended until the balance is paid in full. I understand that I
am free to discontinue my child’s treatment at any time, but I will still be responsible for
timely payment of those services rendered prior to the ending of the assessment.
Health insurance will usually provide some coverage for mental health treatment. The
paperwork will be completed in order to receive those benefits. However, I ultimately am
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responsible for full payment. It is very important to find out exactly what mental health
services the insurance policy covers and if certain services are not covered or expire, I
have the right to pay for those services out of pocket, unless it is prohibited by the
insurance contract. If there are questions about coverage, one needs to call their plan
administrator. Most insurance companies require authorization for a clinical diagnosis
and/or a treatment plan or in rare cases may ask to see the entire file. This information
will become part of the insurance files and once it becomes part of the insurance
company’s records, my therapist cannot control what happens to the information.
The therapist does not perform forensic work nor does she get involved in any legal
proceedings. If circumstances are such that she has to get involved, I will be responsible
for paying for her professional time at $400.00 per hour and I will be responsible for
paying for all of her legal fees. In addition, I understand involving her in a legal situation
may jeopardize the therapeutic relationship and the therapist may choose to terminate
treatment and refer me to another therapist.
The therapist checks his/her voicemail periodically during regular business hours on
weekdays. I understand that if at any time there is an urgent situation that cannot wait for
a return call; I may contact Common Ground’s 24-hour mental health crisis hotline at
(248)-456-0909. If the situation is life threatening in nature, I know that I should go
directly to the emergency room at the nearest hospital or dial “911”
I understand that conversations with a therapist are confidential. No information will be
released without my consent with the following exceptions. By law, the therapist must
report suspected child or elder abuse/neglect to the appropriate authorities. In addition,
the therapist has a legal duty to break confidentiality if a patient presents an imminent
danger to self or to someone else. In case of emergency, information necessary to
provide for the care of the patient may be disclosed. If this is a child and they have a legal
guardian in addition to me, I am aware that those other persons may have access to
information regarding treatment. Any electronic transmissions also cannot guarantee
confidentiality. I am aware that if I become involved in litigation in which my child’s
mental health or welfare is at issue, my child’s treatment records and/or the therapist
herself might be subpoenaed by other parties to the litigation. The therapist may also
consult with a supervisor about my case. When the therapist discusses the case with a
supervisor and/or colleagues, the identity of the patient will not be disclosed.
By signing below, I indicate I have read, understood and agreed to the entire contents of
this consent.
Signature of Child’s Legal Guardian
Printed Name
Date
Signature of Child’s Legal Guardian
Printed Name
Date
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For parents who are not married with full legal custody:
I have sole legal custody of my child:
Signature of Child’s Legal Guardian
Printed Name
Date
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Lori Radner PsyD, L.P.
248-788-6400 Ext. 2
Consent to Disclose Information Form
I, _____________________, guardian for ________________________ give my
permission for:
1. I will allow the following people to give any pertinent information to Lori Radner:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. I would like a report to be mailed to my pediatrician:
Pediatrician’s Name:_______________________________
Address:________________________________________________________________
Phone:__________________________Fax____________________________________
3. I will allow Lori Radner to disclose information regarding treatment/evaluation to the
following people:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
This consent form will be valid for ______________________after the date signed.
Signature of Patient or Legal Guardian
Date