Child Psychological Assessment Consent Form
Please complete this form to provide consent and background information for your child's psychological assessment.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Grandparent
Other
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Assessment
*
Please indicate if your child has experienced any of the following (select all that apply):
*
Difficulty with attention or concentration
Emotional or behavioral concerns
Academic challenges
Social difficulties
None of the above
How would you rate your child's current emotional well-being?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Please rate the following areas for your child:
*
Rows
Never
Rarely
Sometimes
Often
Always
Difficulty following instructions
1
2
3
4
5
Trouble making friends
6
7
8
9
10
Frequent mood changes
11
12
13
14
15
Problems with schoolwork
16
17
18
19
20
Submit Consent
Should be Empty: