Adolescent Intake

  • I hereby authorize Dr. Dimitra Takos, Licensed Clinical Psychologist PSY 29103, to provide services to my child. Provided services include psychological treatment as directed by Dr. Takos. This form is an addendum to the Informed Consent and Services Agreement form, to authorize treatment of your child. In the case of a minor, special sensitivity may be required in releasing information about certain topics such as drugs and sex. I will accept Dr. Takos’ judgment regarding releasing or sharing information obtained during the course of psychotherapy with the minor that may endanger or jeopardize the client's wellbeing.
  • Signature of Parent/Legal Guardian
  • Pregnancy (complications)? Complications during birth? Milestones (on time/delayed)? Temperament, frustration management?
  • Date Format: MM slash DD slash YYYY