Child Specific Consultation Request Form

Site *

Referred by *

Date of Referral *

Child’s Name *

Parent/Guardian Name *

Teacher Name *

Please Input

DOB
Phone

Other

INFORMED CONSENT

I understand that my child ___________________________ has been referred to a Early Childhood Mental Health Consultant (ECMHC) for the reason(s) listed above. I give my permission for the consultant to observe my child and consult with the staff at _____________________ regarding my child’s status, including my child’s behavior at home and school.

I understand that I can withdraw this consent at any time. This consent shall otherwise remain in effect for one year

Signature of Parent/Guardian

Date

Witness

Date

School administration: Please email this Consultation Request Form to:

Cortney McCutcheon, ECMH Consultant
[email protected]

Jenine Zackey, ECMH-C Supervisor
[email protected]

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.