Child Patient 2021 Form Update

New Client Information (Under 18-years old)
Today's Date

Month Day Year
Date
Client Identifying Information
Name

First Name Last Name
Preferred Name
Date of birth

Month Day Year
Date
Age
Gender
If other, please specify
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Voice message okay?

Yes No
Cell Phone Number
Please enter a valid phone number.
Voice message okay?

Yes No
Email
example@example.com
I understand that email may not be secure to third-party intrusion.

Yes No
Preferred pronouns
Adopted

Yes No
School/Current grade/Teacher
Employment

None Part-time Full-time
Parent/Guardian
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
SSN (Required)
Place of Employment:blanks & Occupation: blank
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
I understand that email is not secure to third-party intrusion.

Yes No
Please add this email to the newsletter mailing list

Yes No
Indicate where you prefer to be contacted

Home Phone Cell Phone Work Phone Email
Please indicate where we have permission to leave a message

Home Phone Cell Phone Work Phone Email
I would like email appointment reminders

Yes No
Email address for appointment reminders:
example@example.com
Copy of Parent Drivers License

Cancel of
Co-Parent/Guardian
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth

Month Day Year
Date
SSN (Required)
Place of Employment blanks & Occupation blank
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
I understand that email is not secure to third-party intrusion.

Yes No
Please add this email to the newsletter mailing list

Yes No
Please indicate where you prefer to be contacted

Home Phone Cell Phone Work Phone Email
Please indicate where we have permission to leave a message

Home Phone Cell Phone Work Phone Email
Person Responsible for Payment
The financially responsible adult is the person who signs the Consent for Services Agreement.
Relationship to minor
INSURANCE INFORMATION
Front and Back of Insurance Card

Cancel of
Did you call for Pre-Authorization?

Yes No
If yes, what's your Pre-Authorization Number?
MANY INSURANCE COMPANIES REQUIRE PRE-AUTHORIZATION FOR MENTAL HEALTH AND BEHAVIORAL HEALTH SERVICES. IF THIS IS REQUIRED BY YOUR INSURANCE CARRIER AND YOU DID NOT CALL, BE AWARE THAT YOU MAY BE PENALIZED WITH DENIAL OR REDUCED BENEFITS.

WE ARE NOT IN NETWORK WITH NC MEDICAID. IF YOU HAVE COMMERCIAL INSURANCE, WE WILL GLADLY FILE WITH YOUR PRIMARY INSURANCE, WITH YOU HAVING THE UNDERSTANDING THAT THE COPAY AND/OR DEDUCTIBLE IS THE RESPONSIBILITY OF THE CLIENT.

We will gladly file your insurance for you as a courtesy. However, we must have FULL INSURANCE INFORMATION COMPLETED BELOW. It is up to the client to know his/her insurance coverage, including knowledge of co-payment amounts and yearly deductibles. We cannot verify this information for you. If payment of the bill has not been satisfied by the insurance company within 90 days, it is the responsibility of the client or parent/guardian to pay the bill in full. We will not wait for secondary insurance to pay the balance. Co-payments and deductibles are always due at the time of service.
Child's Name

First Name Last Name
Child's relationship to insured person:
Child's Status:

Single Married Partnered Separated Divorced Widowed Unemployed Part-time Full-time Student Disability Retired
Primary Insurance Company:
Insured Person's Name:

First Name Last Name
Insured Person's Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insured Person's Social Security Number:
Insured Person's DOB:

Month Day Year
Date
Insured Person's Gender

Male Female Other
If other, please specify:
Insured Person's Employer or School:
Where to mail claims:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policy #:
Group #:
Secondary Insurance Company:
Insured Person's Name:

First Name Last Name
Insured Person's Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insured Person's Social Security Number:
Insured Person's Gender:

Male Female Other
If other, please specify:
Insured Person's Employer or School
Address to mail claims to:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policy #
Group #
Client-Clinician Agreement
CONSENT FOR SERVICES FOR A MINOR
I give my consent for psychological services to be provided to my child, blanks by CAROLINA PSYCHOLOGICAL ASSOCIATES, P.A.
I understand that the sessions with Carolina Psychological Associates have been either authorized through my EAP or approved through a Managed Care Insurance program. This may mean that my child can be seen either free of charge to me, or at reduced rates and/or copayments. I agree to pay all appropriate copayments as well as applicable deductibles and for services disallowed for any reason by my EAP/MC program or insurance company. I may or may not be financially responsible for appointments missed or canceled without 24-hour advance notice. I understand that I will forfeit my allotted EAP session(s) for each appointment missed or canceled without 24-hour advance notice. I agree that if I pay by check, my account will be debited electronically for both the face amount and returned check fee ($25.00) if it is returned unpaid. I also understand that I am financially responsible for any collections fees/court costs involved in collecting my past due account. I understand that if I am unable to keep a scheduled appointment, I will notify Carolina Psychological Associates with at least 24-hour advance notice. I understand that I am financially responsible for all phone calls longer than 15 minutes. Payment is required at the time service is provided; however, insurance information will be obtained at the first session and insurance will be filed as a courtesy to me for sessions following the initial EAP sessions. Psychological testing and hospitalization are not covered by EAP’s.
Release and Assignment: I hereby authorize any plan benefits to be paid directly to Carolina Psychological Associates, P.A., and I understand that I am financially responsible for non-covered services, including those for which authorization or payment has been denied, either by my EAP/Managed Care plan or other payor. If a claim is made by me or Carolina Psychological Associates to any insurance company or companies, or to any other third party payor, I do not object to the release by mail, fax, telephone, cell phone or computer modem, any records or other information about me, or my child, or the services which are provided, including without limitation, the complete case record, information concerning any personal, psychological and medical history, information concerning billing and payment for such services. I understand that modern communication modalities, such as cell phone, email, and fax, are subject to difficulties. I understand that Carolina Psychological Associates, P.A. will exercise all reasonable precautions, and I in no way will hold Carolina Psychological Associates, P.A. liable for any difficulties resulting to me or any other family member from the communication of confidential information by means of email, fax or cell phone. I agree that all such information shall be subject to review by such insurance company or third-party payor during the period of my or my child’s treatment by Carolina Psychological Associates or at any other time thereafter. North Carolina State law allows mental health and medical providers to share client information with other mental health providers, without obtaining the client’s written consent, when necessary to coordinate care and treatment. This applies between mental health providers and other health care providers and is regulated by Federal HIPAA Laws (1999). This allows a referring psychotherapist or physician to be informed about a client they have referred.
Parent/Guardian Agreement Not to Use Minor’s Therapy Information/Records in Custody Litigation: When a family is in conflict, particularly conflict due to parental separation or divorce, it is very difficult for everyone, particularly for children. Although the therapist’s responsibility to your child may require them helping to address conflicts between the child’s parents, their role will be strictly limited to providing treatment to your child. You agree that in any child custody/visitation proceedings, neither of you will seek to subpoena the records or ask the therapist or Carolina Psychological Associates, P.A. to testify in court, whether in person or by affidavit, or to provide letters or documentation expressing their opinion about parental fitness or custody/visitation arrangements.
Please note that your agreement may not prevent a judge from requiring their testimony, even though they will not do so unless legally compelled. If they are required to testify, they are ethically bound not to give their opinion about either parent’s custody, visitation suitability, or fitness. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, they will provide information as needed, if appropriate releases are signed or a court order is provided but will not make any recommendation about the final decision(s). Furthermore, if required to appear as a witness or to otherwise perform work related to any legal matter, the party responsible for their participation agrees to reimburse them at the rate of $250.00 per hour for time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs. These fees are not covered by insurance. Carolina Psychological Associates, P.A. is not a forensic practice and does not choose to be involved in litigation, and we are opposed to it as we do not believe it to be therapeutic.

If the parents of a child are separated or divorced and there is joint custody, I understand and consent to the other parents’ notification of treatment of my child as advised by the N.C. Attorney General’s Office.
ATTESTATION AND ACKNOWLEDGEMENT
If you have any questions about the above information, please discuss them with the office manager and/or your therapist. Your signature below indicates that you attest to the information that you provided in these forms and that you have read, understood, and agree to the Client-Clinician Agreement which includes:
- Consent for Treatment
- Confidentiality Agreement
- Electronic Communication and Social Media Policy
- Fee Information
- Emergency Procedures
It also serves as acknowledgement that you have reviewed the HIPAA information that contains the NC Notice Form, the Psychologist-Patient Services Agreement, and the Patient’s Rights and Responsibilities. You may request a copy of these notices for your records.
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Print your name here:

First Name Last Name
Clinician Signature

Clear
Date

Month Day Year
Date
If the client is a minor and there is joint custody between two parents, we also require the consent and signature of the other parent:
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Print your name here:

First Name Last Name
Should be Empty:

New Client Information (Under 18-years old)

Client Identifying Information

Parent/Guardian

Co-Parent/Guardian

INSURANCE INFORMATION

Client-Clinician Agreement

ATTESTATION AND ACKNOWLEDGEMENT