____Associates of Springfield Psychological____                                                                                    
920 West Chester Pike                1489 Baltimore Pike                    709 E. Gay Street                                                                                        
      Havertown, PA 19083                    Bldg. 200, Suite 250                    West Chester, PA 19380                                                                                        
Springfield, PA 19064                                                                                        
Telephone: 610-544-2110                                                                                        
Fax: 610-604-9510                                                                                        



Date:




Child's name:________________________________________
                      Please print

This is to verify that I do not know where to locate or how to contact the parent/guardian
of the above. I recognize that I am responsible to inform the parent/guardian of the above that
their child is in treatment with Associates of Springfield Psychological if I am able to contact them.




Parent/guardian: ________________________________________
                           Please print name


Parent/guardian: ________________________________________
                           Signature