If divorced - medical care legal decision making

Is there another parent/legal guardian in different residence?

Has other parent/guardian been notified of this appt?

Who disciplines child?

Provide information on siblings name/age/sex/relationship with child

Briefly describe the reasons you are bringing your child(ren) to counseling so we can review

Do both parents feel similarly about the child's behavior? Please explain

Important events in last 6 months - please list

Any head injuries or important medical history?

I/We the parent(s) guardian of the minor or individual with a guardian, as listed below, have completed the above information for Pathways Counseling

Signature of Parent/Guardian

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Please chose the style you would like your signature in:

Your Name

Signature of Parent/Guardian 2

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Your Name

Minor child/Dependent information form