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Parents living with child:
Parents living without child:
Relationship to Child
If child: is he/she Child biological, adopted, step or foster?
Occupation or Grade
Name of Psychiatrist/Counselor/Agency
Date(s) of Appointment(s)
The Child & Adolescent Psychiatrists in Saskatoon work together to provide patient care. To ensure that your child receives the best possible service, it may be necessary, from time to time, to communicate between offices on your behalf, both verbally and in writing, to other psychiatrists, physicians or professional mental health staff. All information obtained will remain confidential.
I give my consent for my child's psychiatrist to obtain and release information.