--- title: Pediatric Mental Health Screening Consent Form Template | Paperform description: Professional pediatric mental health screening and consent form with HIPAA authorization, family history assessment, school performance review, and medication tracking for child mental health providers. url: "https://paperform.co/templates/pediatric-mental-health-screening-consent-form" type: static generatedAt: "2026-04-03T00:49:44.235Z" --- [← Back to free form templates](/templates/) ![Pediatric Mental Health Screening Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/pediatric-mental-health-screening-consent-form.png) [Preview](https://_preview.paperform.co/ai-template/pediatric-mental-health-screening-consent-form) [Use this template for free](/create?ai-template=pediatric-mental-health-screening-consent-form) [Healthcare & Medical Forms](/templates/category/healthcare/)[Legal & Compliance Forms](/templates/category/legal/) [Healthcare](/templates/industry/healthcare/)[Mental Health](/templates/industry/mental-health/)[Education](/templates/industry/education/) [Physician](/templates/role/physician/)[Therapist](/templates/role/therapist/)[Counselor](/templates/role/counselor/)[School Counselor](/templates/role/school-counselor/)[Psychologist](/templates/role/psychologist/)[Healthcare Administrator](/templates/role/healthcare-admin/) About this free form template ### Streamline Pediatric Mental Health Screening with a Professional Consent Form Early intervention in pediatric mental health can make a profound difference in a child's development and wellbeing. This **Pediatric Mental Health Screening Consent Form** template provides healthcare providers, school counselors, and mental health professionals with a comprehensive, HIPAA-compliant solution for obtaining proper authorization while gathering essential clinical information. #### Designed for Healthcare Professionals and Educational Settings Whether you're a pediatric practice, child psychologist, school-based mental health program, or community health center, this template captures all the information needed for a thorough initial assessment. The form guides parents and guardians through consent for screening, treatment authorization, and information release while collecting critical data about family history, school performance, current medications, and behavioral concerns. #### Complete Clinical and Administrative Coverage This template goes beyond basic consent by integrating clinical screening questions with administrative requirements. You'll gather parental consent for evaluation, HIPAA authorization for sharing protected health information with schools and other providers, emergency contact details, insurance information, and detailed background on the child's developmental, social, and academic functioning. The structured format ensures you meet compliance requirements while building a complete clinical picture from the first interaction. #### Seamless Workflows with Stepper and Papersign Once a parent submits this form, you can use **[Stepper](https://stepper.io)** to automatically route the submission to your scheduling system, notify the appropriate clinician, update your EMR or practice management system, and trigger follow-up workflows for therapy referrals or psychiatry consultations. With **[Papersign](https://papersign.com)**, you can convert the consent portions into formal documents requiring secure eSignature, creating a legally binding authorization trail that's automatically linked to the original screening submission. #### Built for Compassionate, Efficient Care This template balances clinical thoroughness with a warm, parent-friendly tone. Conditional logic reveals relevant follow-up questions based on responses, reducing overwhelm while ensuring you capture all necessary details. For mental health professionals who want to provide excellent care while maintaining efficient intake processes, Paperform makes it possible to create a professional, branded screening experience that families trust and clinicians can rely on. Built for growing businesses, trusted by bigger ones. Trusted by 500K+ business owners and creators, and hundreds of millions of respondents. ![Capterra - 4.8 out of 5](/images/capterra-st.jpg) ![Trustpilot - 4.8 out of 5](/images/trustpilot-st.jpg) ![G2 - 4.8 out of 5](/images/g2-st.jpg) [Try Paperform free now](/register) ## More templates like this [![Pediatric Anxiety Treatment Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/pediatric-anxiety-treatment-consent-form.png) ### Pediatric Anxiety Treatment Consent Form Comprehensive consent form for pediatric anxiety treatment covering therapy modalities, medication options, school accommodations, and family involvement in the treatment plan.](/templates/pediatric-anxiety-treatment-consent-form/) [![Animal-Assisted Therapy Program Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/animal-assisted-therapy-program-consent-form.png) ### Animal-Assisted Therapy Program Consent Form A comprehensive consent form for animal-assisted therapy programs that screens for allergies, addresses animal behavior risks, confirms handler supervision, and outlines therapeutic benefits for participants.](/templates/animal-assisted-therapy-program-consent-form/) [![Autism Spectrum Screening & Age Verification Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/autism-spectrum-screening-age-verification-form.png) ### Autism Spectrum Screening & Age Verification Form A comprehensive screening form for autism spectrum evaluation that includes age verification, developmental history, school records, and appointment scheduling for professional assessment.](/templates/autism-spectrum-screening-age-verification-form/) [![Executive Function Disorder Screening Quiz](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/executive-function-disorder-screening-quiz.png) ### Executive Function Disorder Screening Quiz A comprehensive screening quiz designed for neuropsychologists to assess executive function challenges, identify attention patterns, evaluate organization difficulties, and receive personalized intervention strategy recommendations.](/templates/executive-function-disorder-screening-quiz/) [![Mental Health Crisis Response Records Request Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/mental-health-crisis-response-records-request-form.png) ### Mental Health Crisis Response Records Request Form A comprehensive form for requesting mental health crisis records to support coordinated care. Includes previous hospitalizations, medication history, treatment team details, and authorization for release of protected health information.](/templates/mental-health-crisis-response-records-request-form/) [![Mental Health Good Faith Estimate Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/mental-health-good-faith-estimate-form.png) ### Mental Health Good Faith Estimate Form A HIPAA-compliant good faith estimate form for mental health therapists to provide uninsured or self-pay patients with transparent pricing information for therapy services.](/templates/mental-health-good-faith-estimate-form/) [![Mental Health Therapy Prior Authorization Request Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/mental-health-therapy-prior-authorization-request-form.png) ### Mental Health Therapy Prior Authorization Request Form Streamline insurance prior authorization for mental health therapy services with this comprehensive request form that captures patient information, DSM-5 diagnosis, treatment plans, and provider credentials in one organized submission.](/templates/mental-health-therapy-prior-authorization-request-form/) [![Online Ketamine Therapy Patient Identity Verification Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/online-ketamine-therapy-patient-identity-verification-form.png) ### Online Ketamine Therapy Patient Identity Verification Form Comprehensive identity verification and psychiatric assessment form for online ketamine therapy programs. Includes medical history screening, medication checks, photo ID upload, and emergency contact details.](/templates/online-ketamine-therapy-patient-identity-verification-form/) [![Residential Treatment Program Application for Adolescent Depression](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/residential-treatment-program-application-for-adolescent-depression.png) ### Residential Treatment Program Application for Adolescent Depression Comprehensive application form for adolescent residential mental health treatment programs, including intake assessment, safety evaluation, academic planning, and family visitation preferences.](/templates/residential-treatment-program-application-for-adolescent-depression/) [![Telehealth Platform Patient Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/telehealth-platform-patient-consent-form.png) ### Telehealth Platform Patient Consent Form A comprehensive patient consent form for telehealth services that covers HIPAA acknowledgment, technology requirements, emergency care disclaimers, and terms of service acceptance.](/templates/telehealth-platform-patient-consent-form/) [![Telehealth Psychiatry Intake Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/telehealth-psychiatry-intake-form.png) ### Telehealth Psychiatry Intake Form A comprehensive psychiatry intake form for telehealth practices that screens symptoms, captures medication history, verifies insurance, and schedules appointments.](/templates/telehealth-psychiatry-intake-form/) [![Telehealth Virtual Consultation Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/telehealth-virtual-consultation-consent-form.png) ### Telehealth Virtual Consultation Consent Form A comprehensive telehealth consent form that covers technology requirements, privacy acknowledgments, HIPAA compliance, and platform usage agreements for virtual healthcare consultations.](/templates/telehealth-virtual-consultation-consent-form/)