INTAKE PACKAGE FOR MINORS

Intake Package Minor
I. Sociodemographic Information:
Clients name

First NameLast Name
Age:
Date of Birth

MonthDayYear
Date
Gender:

FemaleMale
Telephone
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Relationship
Contact Person / Telephone
Language used at home:
Primary
Secundary
List the reasons for seeking services and your main concerns.
How did you hear about us?
Name of the person filling this form and relationship.
II. Family History:
Parent / Guardian full Name:
Age:
Home address( if different from client)
Occupation:
Preferred Language:
Home phone:
Email:
Work phone:
Cell Phone:
Parent Guardian full name:
Age:
Home address if different from client:
Occupation:
Preferred Language:
Home phone:
Business phone:
Cell phone:
E-mail
If the minor doesn’t live with their parents or either one of them is dead, please explain here:
Parents are:

MarriedDivorcedSeparatedNever Married
Custody agreement:

Court stipulatedAgreement between parents
How the agreement works:
Time spend with each Father:
Mother:
Father:
Other Family member:
Agreements

Child Support ProgramAgreement between parentsDon't get any monetary support
Is there a custody case open or court order involving the child?

YesNo
BMW requires a copy of the divorce certificate or child custody agreement to be on file.

Family Composition:
Name (biological and incidental if different)
Age / Relationship with child
III. Family history of medical conditions:
Condition

Psicosis (hallucinations, schizophrenia, distortionSuicideDepressionAnxietyMental deficiencyHyperactiveLearning problemsEpilepsy and or convulsionsConduct problemsNeurological or neurodevelopment problemsAlcoholismDrug abuse/ dependencyCancer historyCardiovascularDiabetesHypoglycemiaThyroidViolence induced traumaOther
Conditions /Relationship with clients
IV. Developmental History:

(if we cannot obtain this information, please make a note in the margins);
Any Important Remarks?
Does the individual get up many time in the night?

SometimesSleep all night
Peri-natal (while in labor)
Current Diagnoses:
Age at time of Diagnosis
Doctor:
Current Medication(s):
Dosage:
Physician:
Purpose:
Do any of these medications have effects on Individual behavior? If so, explain the effects?

History

	Yes	No
Planned pregnancy by father
Desired pregnancy
Planned pregnancy by mother
Desired pregnancy

Mothers age during pregnancy
During what month did you start pre-natal care
How many pregnancies have you had?
Have you had an abortion before?

Pre- Natal

	Yes	No
Did you experience any trauma during pregnancy? Ex. Vehicular accident, falls, domestic violence, emotional, other:
Bleeding (on which pregnancy month
Vomits
Weight gain (+ 25 pounds)
Weight gain - (25 pounds)
Miscarriage
Tobacco use
Alcohol use
Drugs used (include medications)
Preeclampsia
Diabetes
Hypertension
Other conditions:

Family relations during the pregnancy.
Mother emotional condition during pregnancy.
Other conditions:
Post -Natal

History
Where was the client born? (hospital, clinic, house, etc)

Post - Natal - please choose all that apply

	Yes	No
Natural labor
C section
Forceps?
Induced labor?
Anesthesia (general, spinal, epidural)
Born with the umbilical cord around the neck
Was the newborn yellow? (icteric)
Purple? (cyanotic)
Difficulty breathing?
Incubator?
¿Neonatal ICU?
Did mother and child were released from hospital same day?
Was newborn breastfed?
Conditions diagnosed at birth.
Poor appetite
Difficulty breast feeding
Colics
Constipation
Diarrhea
High fever
Convulsions (under what circumstances and frequency)
Falls
Asthma
Allergies
Respiratory problems
Ear infection
Hearing problems
Visual problems
Cardiac problems
Have you used medications for a long time
Chronic conditions

Conditions diagnose at birh
If child was in Incubator - For how long?
Medications name:
Client’s psychomotor development and behavior during infancy.
He or she started to:

Smile (2-3 m)Turn over (2m)Sitting with help (2-3 m)Crawling alone (6-7m)Saying words (10m)Waking alone (12-15m)Saying phrases (2y)Complete sentences (3y)Eats alone (3y)Gets dress alone (4y)doesn’t pee in bed (5y)able to Tie shoes (6-7y)Gets up at nightSometimesSleeps all night
V. Medical History:
Current Diagnoses:
Diagnoses / Age at the time of the diagnosis / Doctor
Current Medications:
Medication / Dosage / Physician / Purpose
Does any medication effects your child’s behavior? If so, what effects
Medication

Additional medical or physical problems

	Yes	No
Gastrointestinal problems
Allergies
Ear infections
Sinus infections
Headaches
Other

Description of diagnoses
Condition’s history, hospitalizations, dates.
Surgery’s history, dates, complications, use of anesthesia.
Accidents, fractures, lesions, when, how it happened, what part of the body was affected, results?
Food or medication’s allergies, reaction, management.
Tobacco, alcohol or drugs use. Past and present experiences
Gastric movements (regular or irregular), consistency, frequency, pain, what makes it better.
Nutritional habits (how much water, fruits & vegetables do you eat)
Name of person filling form and relation with individual:
Date of completion

MonthDayYear
Date
Communication skills
How does your child communicates his or her needs? ( check all that apply)

WordsSignsGestureother
Briefly summarize your child’s language abilities (known words, known sounds, amounts of words used each day, etc.):
VI. Educational History:

Did child attended?

	Yes	No
Attended pre-kinder
Attended Kinder

Name:
County:
Age attended pre-kinder
Age attended kinder
Current Grade:
School Name:
County:

Does the child present:

	Yes	No
reading problems
writing
math
speech
behavior

If you answered yes in speech or behavioral, provide company’s name/ how often per week/ start and end date:
Speech therapy:
Occupational therapy:
Physical therapy
Applied Behavioral Analysis
Does your child have an IEP/504?
What kind of classroom
Teacher to student ratio:

Habits

	Yes	No
Study habits
Hold back
Skip classes
Been suspended
Expelled
Switch schools

How does he/she feel at school?
(Concerns teachers might have expressed)
Describe client’s actual academic achievements:
VII. Psychological and psychiatric History
Mental health history. Provide reason, dates, name of professionals, institutions, hospitals visited. Copy of existing psychiatric, psychological, psychometric or psych educative evaluation.
Behavioral problems:

( tantrums, aggression, defiant behavior, elopement-running away, etc.)
Behaviors (choose which one apply)
Tantrums, aggression, defiant behavior, elopement - running away.
Description (describe each one that apply)
Tantrums, aggression, defiant behavior, elopement - running away.
Tantrums (Frequency)

HourlyDailyWeekly
Aggression (Frequency)

HourlyDailyWeekly
Defiant behavior (Frequency)

HourlyDailyWeekly
Elopement - running away (Frequency)

HourlyDailyWeekly
Tantrums( Duration )

SecondsMinutesHours
Aggression ( Duration )

SecondsMinutesHours
Defiant behavior ( Duration )

SecondsMinutesHours
Elopement - running away ( Duration )

SecondsMinutesHours
Tantrums ( Severity )

HighMediumLow
Aggression ( Severity )

HighMediumLow
Defiant Behaviors ( Severity )

HighMediumLow
Elopement - running away ( Severity )

HighMediumLow
Client's description

CalmActiveHighly active
The child tends to play with:

kids his ageyoungeroldersame genderopposite genderwith brother/sisterwith parentsalonedo not play

The child:

	Yes	No
Independent
Nightmares
Sleepwaking
Sleep Takes
Teeth grinding

What in home activities (physical, sports, dolls, action figures, cartoons, series, movies) does the client like? (describe)
What’s the client’s support system?
What is the child’s favorite food?
Religious or spiritual believes? (Describe)
Do you smoke?

YesNo
Explain, if yes:
Do you drink alcohol?

YesNo
Explain, if yes:
Any illegal drug use?

YesNo
Explain, if yes:
Who disciplines the client and in what ways?

Does the child ( please choose all that apply

	Yes	No
Fear
Nail biting
Pulls hair in head, eyebrows, etc.
Self - Harm ( cuts, bites or other)
Other

Specified other
How does client manage stress (frequency? last time)?
How does client manage sadness (frequency and when was the last time)?
How does client manage anger (frequency and when was the last time)?
Have you ever had a psychological and/ or psychiatric intervention? (reason, date, name of the professional, agency, institution, or hospital. If you have an existing psychiatric, psychological, psychometric, and/ or neurological testing please include.)
VIII. Legal Information:
Do you have

YesNo
Why?
Any pending criminal case?

YesNo
ADA assign:
Criminal #
Next Court Date

MonthDayYear
Date
Any civil case:

YesNo
Case Number
Next court date:

MonthDayYear
Date
Name of Lawyer (if apply)
Court
Assigned Judge
Was the child removed by the court from his biological parents:

Yes No

Please choose
Date of the removal

MonthDayYear
Date
Reason for removal
Case number:
Agent and #
Where did the complaint happened?:

	Yes	No
Please choose

Type a question

	Yes	No
Are any pending cases?
Civil case

# if Civil case
Civil case date

MonthDayYear
Date
Prosecutor assigned
Criminal #
Next court date:

MonthDayYear
Date
Assigned court Social Worker (if apply)
Court
Assigned Judge
Permanent custody
Temporary custody
Parental Rights
Physical custody and actual residency: Biological father/ mother.
Personal Rights:

FosterFoster groupAdoptive parentsOther
IX. Sexual History
Is the patient sexually active? Please, describe previous relations, sexual development, or sexual behaviors:
Date

MonthDayYear
Date
Signature Person completing history (Parents or Legal Guardian)*

Clear
VIII Trauma History
Are there any trauma history, if so explain:
THERAPEUTIC/ASSESSMENT SERVICES AGREEMENT (CHILDREN)
Date

MonthDayYear
Date
Please fill out the guardians name: I provide consent for my clhied to receive services from,
. Behavioral Mind & Wellness.
I certified I have been properly oriented about the following:

1. All information related to service/treatment will be confidential unless my child or other emotional or physical security was at risk.2. I voluntarily consent for my child to participate of this services /treatment, understanding I can withdraw my consent in writing at any moment without penalty.3. Individual therapy takes 45 minutes; family takes 50 minutes and group therapy one hour. The psychological and psychometric assessments duration will be decided by the professional.4. I understand the relation between the professional and me/my child is strictly and exclusively professional.5. Professionals cannot receive presents of any kind.6. I understand it’s my responsibility to inform BMW of any appointment cancellation at least 24 hours in advance.7. I understand the need to attend appointments on time; not complying forces the professional in charge to reschedule the appointment to a later day and you might be charged a cancellation fee.8. Professional may discuss you case with other BMW employees.
BMW explained to me in simple language, all pros, and cons of participating in the services/treatments they offer, including material risks, benefits, and other alternatives
Guardian Signature*

Clear
Guardian name
Date

MonthDayYear
Date
Consents & Orientation
Client name
Date of birth

MonthDayYear
Date
HEALTH & SAFETY: I received a copy of the Health & Safety document and its content was explained to me.

CLIENT ́S RIGHT: I have received a copy of the Client ́s Right document, and its content was explained to me.

CONFIDENTIALITY/PRIVACY: I understand all client information is private in nature and it won’t be shared without my consent, except in one of the following events:
- Suspicion of abuse or negligence against a child/elderly/incapacitated adult.
- An abuse/negligence investigation/case exists.
- Someone’s life is in danger.
- Court information request order.
After my consent, BMW will only share information strictly necessary for an assessment, coordinated treatment, notifying people if it is a mandatory treatment or other purposes as specified in the Notification and Release of Information document.

AUTHORIZATION TO CONSENT: I certify I have the legal authority to consent to a mental health treatment information release related to the client mentioned above. I will immediately notify BMW if my status as a legal guardian (in case of a minor or incapacitated client) changes and will provide the name, address, and phone number of the new legal guardian.

CONSENT FOR TREATMENT: I provide my consent to the client mention above to participate in Behavioral health assessments and treatments at BMW, including the sharing of relevant confidential information with other professionals working on the case:

FUNDING AUTHORIZATION: I authorized BMW to share confidential information with my health insurer in case of a reclaiming process, obtaining compensation, and to comply with audits required by them. ** I understand that I am responsible for any charges that the health insurance will not cover, including any services provided after a denied claim. I understand I may revoke this consent at any moment; however, I cannot revoke my consent for actions already taken. A copy of this release is as valid as the original.
Behavioral health assessments and treatments at BMW, including the sharing of relevant confidential information with other professionals working on case:

School teachersFamily members.Case managers or treatment professionals:
Case Manager or treatment professional
Please check all as evidenced that you read it.

HEALTH & SAFETYCLIENTS RIGHTCONFIDENTIALITY / PRIVACYAUTHORIZATION TO CONSENTCONSENT FOR TREATMENTFUNDING AUTHORIZATION
THIS CONSENT EXPIRES A YEAR AFTER IT WAS SIGNED.
Signature Clients Parents or Legal guardian *

Clear
Date

MonthDayYear
Date
No Show/Cancellation Policy
Clients name
Date of birth

MonthDayYear
Date
Client name: Irregular attendance and “no shows”, are costly to your treatment plan. It is therefore your responsibility to attend all scheduled appointments. CANCELLATIONS AND NO-SHOW POLICY: All cancellations must be done by phone at least, 24-hours
- After the first cancellation, the staff will call you to reschedule.
- After two cancellations in a row, BMW will send you a letter explaining you must call in if you want to continue services.
- After the third cancellation in a row, services will be terminated.
NO SHOW POLICY: If you fail to cancel 24 hours before a scheduled appointment, it will be considered a “No
- Show”.
- No shows will be charged $95.00.
- First “No Show”, you will be charged $95.00 and the staff will call to reschedule the appointment.
- Second “No Show”, the Administrator will send you a letter notifying services have been suspended and that you are required to pay the no show fee of $95.00 to reinstate services.
- After the third “No Show”, you will be charged $95.00 and your case will be closed.
No shows, cancelations and service terminations for services ordered by DOJ, DCF or Courts in general, will be notified to your case manager or probation officer.

I agree with BMW’s No Show/Cancellation policy; understanding regular attendance is necessary for treatment to be effective. I will attend all scheduled sessions and will call in 24 hours in advance for any reschedule. Client signature/Legal guardian: Date:
Signature Clients parents or legal guardian signature *

Clear
Date
Primary Care Physician (PCP) Notification
Client name
Date of birth
The primary care physician for this client is: PCP
Mailing Address
Phone / Fax:
Email
Purpose of Release:

FOR NOTIFICATION PURPOSES ONLY
This document notifies Primary Care Physicians about counseling and/or assessment services provided to their patients by Behavioral Mind Wellness (BMW):
Treatment or assessment reason:
Date:
Clinician Name:
Clinician Telephone #:
Acknowledgement:
By signing below, BMW to release a copy of this document to the PCP name above and the exchange of confidential information between the PCP and my BMW clinician for treatment coordination purposes.

BMW contact information: □ 417 W Vine St, Kissimmee, Florida 34741 (321)888-6965 Bmindwellness@gmail.com

* I understand I may refuse to sign this authorization and my refusal to sign will not affect my ability to obtain treatment from BMW. I may revoke this authorization in writing at any time; however, I cannot revoke authorization for actions already been taken.

* A copy of this release shall be as valid as the original.

THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.
Parent or legal guardian name
Signature*

Clear
Signature Caregiver

Clear
Date
Consent to interview another person as part of the treatment
I
give authorization to_____________________ to interview part of my treatment in Behavioral Mind Wellness: Evaluation, Prevention & Treatment, LLC.
Name of the person you authorize to interview
Signature Client parent or guardian *

Clear
Date

MonthDayYear
Date
Your appointment Info:
Date of the appoinment
What to Expect at Your Psychological Evaluation
Psychological assessments seek to provide information about a specific question pertaining to psychological, cognitive, or emotional functioning using standardized and empirically validated tools. The results might be of great value in accessing specialized services, qualifying for educational or occupational accommodations, clarifying the nature of emotional or cognitive symptoms, and designing treatment interventions.

Psychological assessments are intensive and usually consist of an interview, several testing sessions, a feedback session to go over the results, and the preparation of a written report. The overall time required depends on the nature of the assessment and the consultation question that is being addressed. There can be no guarantees about the outcome of a psychological assessment. Undergoing a psychological assessment may involve discussing unpleasant aspects of your life and may lead to unanticipated results and/or conclusions you find to be discomforting. We attempt to minimize these risks by thoroughly reviewing the nature and purpose of the testing with you and explaining the results in a language you can understand.

The first appointment is usually 1 hour where you will participate in a clinical interview. If the client is a minor child, the parent/legal guardian must be present for the clinical interview.

The second appointment is usually 4 hours of active testing. There will be several breaks during this time.
- The third and final appointment is usually 1 hour where the client and the parent/legal guardian (as applicable) will receive feedback and test results, getting a chance to ask questions. You will also receive a copy of the test results. To ensure the best results for your Psychological Evaluation, please remember the following:
- Wear prescription glasses when required.
- Take all medications prescribed.
- Have a bite prior to the session.
- Bring a snack. Water is provided.
- Please arrive at your appointment on time!
Please call the office at (407) 785-3265 or (321) 888-6965 if you have any questions.
TELEHEALTH SERVICES CONSENT
Clients (patient or guardians name)
I (patient or guardians name) hereby consent to Telehealth Services, Psychotherapy, and or Medication Management with BEHAVIORAL MIND WELLNESS as part of my treatment. I understand “Tele-health” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. Tele-health also involves sharing my medical/mental information, both orally and visually, with other health care practitioners located in Florida. I understand I have the following rights:

1. I may withhold or withdraw consent at any time without affecting my right to future care or treatment.

2. Laws protecting the confidentiality of my medical information also apply to Tele-health. Information disclosed during my treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elderly, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and when my mental or emotional state is an issue in a legal proceeding. The dissemination of any personally identifiable images or information from a Telehealth interaction to researchers or other entities shall not occur without my written consent.

3. There are risks and consequences from Tele-health, including, but not limited to, the possibility, despite reasonable efforts on the part of my treatment, that: the transmission of my medical information could be disrupted or distorted by technical failures; or the transmission could be interrupted by unauthorized persons; and or the electronic storage of my medical information could be accessed by unauthorized persons.

4. I understand Tele-health-based services and care may not be as complete as face-to-face services. If my provider believes I would better benefit from another form of services (e.g., face-to-face services), I will be referred to a provider who can provide such services.

5. There are potential risks and benefits associated with any form of psychiatric or psychotherapy services, and that despite my efforts and the efforts of my provider, my condition may not improve, and in some cases, may even get worse. I understand I may benefit from Tele-health, but that results cannot be guaranteed or assured.

6. I understand I have a right to access my medical information and copies of medical records in accordance with Florida state law. I have read and understood the information provided above. I have discussed it with my provider, and all my questions have been answered to my satisfaction. My signature below indicates my informed and willful consent to treatment.

THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.
Parents or legal guardians signature*

Clear
Date

MonthDayYear
Date
HIPAA AUTHORIZATION FORM BEHAVIORAL MIND WELLNESS
This authorization is for the use or disclosure of protected health information required by the Health Insurance Portability Act, 45 C. F. R. Parts 160 and 164.

I authorize Behavioral Mind Wellness to use and disclose the protected health information described below to:
I. AUTHORIZATION ( Names of persons or offices to provide information)
PCP etc
II. EFFECTIVE PERIOD ( This authorization for release information covers the period of healthcare from):
PCP etc
OR.

Past, present and future periods.
III. EXTENDED OF AUTHORIZATION

I authorize to release my complete health record (including records to mental health care, infection disease, HIV, AIDS and alcohol or drug abuse treatment).
OR.

I authorize to release of my complete health record except for the following information:mental health carecommunicable diseases (including HIV or AIDS)alcohol or drug abuse treatmentOther
IV. The medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct
V. This authorization shall be in force and effect until ______________________ (date or event) at which time this authorization expires.
VI. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not sufficient to the extent that any person or entity has already acted in reliance on my authorization or if they obtained my permission as a condition of receiving insurance coverage. The insurer has a legal right to contest a claim.

VII. I understand that my treatment, payment, enrollment, or eligibility for benefits will is not conditioning on whether I sign this authorization.

VIII. I understand that information used or disclosed according to this authorization may be informed by the recipient and may no longer be protected by federal or state law
Date

MonthDayYear
Date
Should be Empty:

Intake Package Minor

I. Sociodemographic Information:

II. Family History:

Time spend with each Father:

BMW requires a copy of the divorce certificate or child custody agreement to be on file.

III. Family history of medical conditions:

IV. Developmental History:

Post -Natal

Client’s psychomotor development and behavior during infancy.

V. Medical History:

Communication skills

VI. Educational History:

If you answered yes in speech or behavioral, provide company’s name/ how often per week/ start and end date:

VII. Psychological and psychiatric History

Behavioral problems:

VIII. Legal Information:

IX. Sexual History

VIII Trauma History

THERAPEUTIC/ASSESSMENT SERVICES AGREEMENT (CHILDREN)

Consents & Orientation

No Show/Cancellation Policy

Primary Care Physician (PCP) Notification

Purpose of Release:

Acknowledgement:

Consent to interview another person as part of the treatment

Your appointment Info:

What to Expect at Your Psychological Evaluation

TELEHEALTH SERVICES CONSENT

HIPAA AUTHORIZATION FORM BEHAVIORAL MIND WELLNESS