Child Intake Form

Child's Information
Full Name (first, middle initial, last):*
Preferred Name:
Date of Birth:*

MonthDayYear
Date
Age of Patient:*
Gender:*
Street Address:*
Zipcode:*
State:*
Cell phone number:*
Email:*
example@example.com
Secondary phone number (optional):
Type NA if you do not wish to provide a secondary phone number.
Insurance Company:*
Policy/Member/ID Number:*
Group:*
Primary Insurance Holder:*
Relation to client:*
Primary Insurance Holder DOB:*
Primary Insurance Holder Social Security Number:*
Employer (if policy through work):
Name of person completing this form*
Relationship to Patient:*
I. Please describe, in detail, the present problem (including when the problem started, how often it occurs, what stressors may contribute to the problem, etc.)*
This information will be released to your child's therapist.
Name of Pediatrician or Family Doctor:*
Date last seen:*

MonthDayYear
Date
Please check all that apply:

SeizuresHeart ProblemsWeight ProblemsHead InjuryAsthmatic conditionChronic FatigueChronic HeadachesDepressionChronic Hearing LossStomach ProblemsSuicidal ThoughtsSurgeriesOther
Please explain any item that you checked and list any medication(s) that were previously prescribed.*
Type NA if this question does not apply to your child.
Allergies (Please list all of your child's allergies):*
How much did your child weigh at birth?*
Please put your answer in pounds (lbs).
Were there any problems at birth?*

YesNo
If yes, explain:
Type NA if this question does not apply to you.
Please select all that apply to your child's temperament when they were a baby/toddler:*

Did not enjoy being heldExcessive restlessnessColicFeeding problemsSleep problemsHead bangingSensitive to light / noise / textureFussy or unhappyDifficulty bondingNone of the aboveOther
If other, please describe:
Type NA if this question does not apply to you.
At what age did your child...
Be able to sit up alone?*
Walk?*
Put words together?*
Finish toilet training?*
Please select all of the unusual behaviors that apply:*

SpinningPutting things in the mouthRepeating words or phrases inappropriatelyHand flappingSniffing excessivelySaying "I" for "You"None of the aboveOther
If other, please describe:
Type NA if this question does not apply to you.
Did your child attend daycare?*

YesNo
If yes, what was their age?
Type NA if this question does not apply to you.
Any problems in daycare?
Type NA if your child did not attend daycare.
What were your child's grades on their last report card?*
What is the name of your child's primary teacher?*
What grade is your child in?*
Please list all of the schools your child has attended, including the one they are enrolled in now. Please include what grades they were in at each school. *
Has your child ever been evaluated for a learning disability?*

YesNo
When?
Type NA if this question does not apply to you.
Has your child ever been in a special education class?*

YesNo
If yes, what type of class?
Type NA if this question does not apply to you.
If yes, when?
Type NA if this question does not apply to you.
Has your child ever been suspended, expelled, or reported to juvenile court?*

YesNo
If yes, please describe:
Type NA if this question does not apply to you.
Has your child ever been assigned to a parole officer?*

YesNo
If yes, their name:
Has your child ever been arrested or in jail?*

YesNo
If you answered yes to any of these questions, please explain:
Type NA if this question does not apply to you.
Is there any family medical history which might be pertinent to the child's therapeutic treatment?*
Type NA if this question does not apply to you.
Biological mother's full name:*
Biological father's full name:*
Biological Parents' Relationship?*

Married to each otherDivorcedSeparated
If the biological parents are divorced or separated, who has custody of the patient?
Type of custody?
Stepmother's name:
Type NA if this question does not apply to you.
Stepfather's name:
Type NA if this question does not apply to you.
Select any of the following that may affect your child:*

Family financial problemsFamily relationshipsLegal problemsChild rearing problemsDrug or alcohol problemsAbuse behaviorHealth problemsEmployment problemsSchool problemsPeer relationshipsFrequent change of householdFrequent moves"Other" problem
If other, please describe:
Type NA if this question does not apply to you.
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS DOCUMENTATION CAREFULLY.

1. Uses and Disclosures for Treatment, Payment, and Health Care Operation I may use or disclose your protected health information (PHI), for treatment, payment, and health care operation purposes with your consent. To help clarify these terms, here are some definitions: - "PHI” refers to information in your health record that could help identify you. - "Treatment, Payment, and Health Care Operations" 1. Treatment is when I provide, coordinate and/or manage your health care and other services related to your health care. An example of treatment would be when I consult with another healthcare provider, such as your Primary Care Physician or another Psychotherapist. 2. Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility and/or insurance coverage. 3. Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, case management, and care coordination. - “Use” applies only to activities within my office [office, clinic, practice group, etc.,] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. - “Disclosure" applies to activities outside of my (office, clinic, practice group, etc.), such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An "authorization” is written permission above and beyond for the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, or health care operations, I will obtain an "authorization” from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy notes. "Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, and/or family counseling session, which I have kept separate from the rest of your clinical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or Psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent not Authorization I may use or disclose PHI without your consent or authorization in the following circumstances: - Child Abuse: If I am treating a child and I know or suspect that child to be a victim of child abuse or neglect, to a duly constituted authority. - Adult and Domestic Abuse: If I have reasonable cause to believe an adult, who is unable to take care of himself or herself, has been subject to physical abuse, neglect, or exploitation, sexual abuse, emotional abuse, I must report this belief to the appropriate authorities. - Health Oversight Activities: If the Alabama Board of Examiners in Psychology, Social Work, Counseling, or Marriage/Family Therapy is conducting an investigation unto my practice, then I am required to disclose PHI upon receipt of a subpoena from the Board. - Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information without the written authorization of you or your legally appointed representative or a court date. The privilege does not apply when you are being evaluated for a third party or here the evaluation is court ordered. You will be informed in advance if this is the case. - Serious Threat to Health or Safety: I may disclose PHI to the appropriate individuals if I believe in good faith that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of you or another identifiable person(s). - Worker's Compensation: I may disclose PHI as authorized by and to the extent necessary to comply with laws relating to work's compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

IV. Patient's Right and Psychotherapist's Duties Patient's Rights: - Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of PHI. However, I am not required to agree to a restriction you request. - Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. For example, you may not want a family member to know you are seeing me. On your request, I will send your bills to another address. - Right to Inspect and Copy: You have the right to inspect and/or obtain PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. You may inspect and copy Psychotherapy notes unless I make a clinical determination that access would be detrimental to your health. On your request, I will discuss with you the details of the request and denial process. - Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process. - Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI. On your request, I will discuss with you the details of the accounting process. - Right to a Paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive notice electronically. Psychotherapist's Duties: - I am required by law to maintain the privacy of PHI regarding you and to provide you with notice of my legal duties and privacy policies and practices with respect to PHI. - I reserve the right to the privacy policies and practices described in this notice. - If I revise my policies and procedures, I will provide a notice to you by mail.

V. Complaints If you are concerned that I have violated your privacy rights, or you disagree with a decision | made about access to your records, you may contact our HIPAA Compliance Officer at 1-800-368-1019 for further information. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The contact number listed above can provide you with the appropriate address upon request.

VI. Text Message Reminders Upon implementation of the new text message reminder service, please be advised that your phone service provider might have fees for or associated with sending and receiving SMS/text messages. Also, these reminders are a courtesy, along with reminder calls and reminder cards, and it is your responsibility to schedule and keep appointments, or to cancel with at least 24 hours' notice to avoid a possible late cancellation charge. VII. Effective Date, Restrictions, and Changes to Privacy Policy This notice has been in effect since April 14th, 2003, with revisions made February 7th, 2020. reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. If I revise my policies and procedures, I will provide a notice to you by mail.

I understand that I am responsible for obtaining prior authorization from my insurance carrier. We will bill your insurance if your provider is on your insurance panel. You are responsible for copayment amounts and deductibles as set by your insurance plan. These payments are due and payable at each appointment. If your insurance changes, you will immediately inform the front office staff. At any time during your treatment, if you become ineligible for insurance coverage, please notify your provider or the office staff. If you are not covered by any insurance plan, or your practitioner is not on your insurance provider panel, you agree to pay for the services in full or at the agreed-upon Self Pay rate at each appointment. If you have insurance that you would like to file yourself, the office staff will provide you with all the information necessary to file your own claims. We check insurance benefits as a courtesy but cannot guarantee coverage.

Fees for Late Cancellations and/or Missed Appointments: Scheduled appointment times are reserved especially for you. If an appointment is missed or cancelled with less than 24 hours' notice, you may be billed in full for the missed or cancelled appointments. Your insurance company cannot be billed for fees associated with missed or cancelled appointments. We call and/or text clients to remind them of appointments as a courtesy and provide reminder cards for your convenience. If you come in on a cancellation call basis, your original appointment or other previously scheduled appointments will not be cancelled unless you explicitly request such.

Fees for Additional Non-Covered Services or Assessment: Your provider is responsible for informing you of the assessment costs when you are beyond or outside your benefits. For special modalities of treatment not covered by your benefit plan (for example, psychological testing or family therapy), the agreement should outline your understanding that it is not a covered benefit and state the fees you will be responsible for. There will be a $30.00 charge for checks returned by your bank for non-payment. When paying in cash, we ask that you have correct change, as we do not keep change in the office. We accept all major credit cards for your convenience, unless otherwise stated by your provider.

Release of Information to obtain Payment for Services: I agree to pay all expenses not covered by insurance or as indicated below. I authorize the release of information to any insurance company for all claims. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the parties who accept assignment. By clicking on the box below, I agree to all terms and conditions of payment and collections, and in case of default agree to pay all costs of collection or attempts to collect, including but not limited to reasonable attorney fees and court costs. The provider reserves the right to retain a Collection Agent, to notify the Credit Bureau and to initiate proceedings in Small Claims Court. This Agreement is governed by the laws of Alabama.

By electronically signing your signature below, you agree to these terms.
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Child's Information

At what age did your child...