Adolescent/Child Intake Packet

Adolescent/Child Intake Packet
Date

MonthDayYear
Date
Name
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState / Province

Zip
Gender

MaleFemale
Select Ethnicity:

Hispanic or LatinoNot Hispanic or LatinoUnknown
Select Race:

American Indian or Alaska NativeAsianBlack/African AmericanNative Hawaiian or Pacific IslanderWhiteOther RaceDecline to Specify
Home Phone
Work
Cell
Best method to contact to confirm appointment:

EmailPhone
Safe Email
example@example.com
Safe Phone #
Employer
Marital Status
Please select the title of the responsible party:

Mr.Mrs.Ms.MissDr.Jr.IIIIIIOther
Responsible Party Name
Gender
DOB
Relationship to Patient
Select Ethnicity:

Hispanic or LatinoNot Hispanic or LatinoUnknown
Select Race:

American Indian or Alaska NativeAsianBlack/African AmericanNative Hawaiian or Pacific IslanderWhiteOther RaceDecline to Specify
Employer
Insurance Carrier
Subscriber Name
Subscriber ID
Group Name
Group #
General Authorization For Treatment
As a person(s) served: I do authorize the clinician(s) at Community Health Partners, Emotional Wellness Department to administer assessment and treatment specified below.

Biopsychosocial assessment and treatment including individual therapy, trauma therapy, EMDR, group or family therapyOther
I understand that my consent can be revoked orally or in writing prior to, or during the treatment period. I understand that claims will be processed on my behalf. I understand that unless this service(s) is fully covered by my insurance plan, fees for services and application to deductible may apply. I have read and had this information fully explained to me. I have had the opportunity to ask questions and receive answers about my treatment. The Emotional Wellness Department of Community Health Partners, does on occasion and where appropriate provide disability letters, letters regarding your ability to work, or letters that would inform providers of your mental health history. You must discuss these needs with your therapist in advance. If a letter is required attesting the client’s needs the therapist will need a minimum of 72 hours’ notice for completion. Letters are only provided to clients who have been seen for 3 sessions or longer. The Emotional Wellness Department does not provide companion/emotional support animal letters. Clients are discouraged from having the therapist subpoenaed. Though the client’s attorney, who initiates the subpoena request is responsible for the court appearance and testimony fees, it does not mean that the therapist's testimony will be solely in in the client's favor. The therapist will only testify their professional opinion and to the facts of the case. Additional fees and costs may apply that are not covered by insurance for legal preparation, appearance and testimony.
Signature of Person Served or Parent/Guardian

Clear
Date

MonthDayYear
Date
Rights of Person Served
You are in partnership with Community Health Partners when receiving services.
- To be treated with dignity, courtesy and respect
- To ask for, consent for and receive quality treatment and services
- To receive services regardless of your place of residence, sex, race, age, sexual preference, national origin, ancestry, immigration status, veteran status, disability, or religion
- To maintain your legal and civil rights unless in Baker Act status
- To participate in the development, understanding and maintenance of your treatment
- To have reasonable access to records
- To supply, whenever possible, accurate information about illnesses, hospitalizations, medications, and other pertinent matters related to your physical and emotional health
- To respect the rights of all others and be considerate of them, including their privacy and confidentiality
- To report physical or mental abuse
- To keep your scheduled appointments, keeping missed appointments to a minimum and contacting within 24 hours if you need to cancel or reschedule your appointment
- To fully participate in your treatment
Community Health Partners rights are:
- To refuse service provision after you continually disregard your treatment, including no-showing three (3) times. Clients with three or more no-shows will be discharged from the practice for one year.
- To refuse service provision to those clients/cases/situations that cause a professional conflict or threat to the clinician, the agency or the mission and vision of the practice.
- To report all suspected, disclosed, witnessed and/or confirmed abuse of a child or vulnerable adult to the Department of Children and Families and other necessary agencies.
- To give notice of your involuntary admission to your emergency contact person
Signature of Person Served or Parent/Guardian

Clear
Date

MonthDayYear
Date
PHONE/EMAIL CONTACT CONSENT AND AUTHORIZATION
For The Emotional Wellness Program
, with respect to any services provided or that are planned to be provided to myself as the patient or, as an authorized legal representative, for the below listed individual as the patient, fully consent to and authorize Naples Physician Hospital Organization dba Community Health Partners, "Healthcare Provider" or any of its automated systems to contact me via phone including to my cellular phone by way of phone call or text message and/or email in relation to any services received from Healthcare Provider or any services planned to be received from Healthcare Provider including any billing items and/or appointment reminders
I am the:

PatientParent/Legal Guardian
Dependent's Name (if you are the Parent or Legal Guardian)
I consent to be contacted via the following method(s):(PLEASE DO NOT PROVIDE WORK
EMAILS OR WORK PHONE NUMBERS
Text Message, to the following personal phone number
Email Message to the following personal email address
example@example.com
Voicemail Message to the following personal phone number
The automated system will try to contact you, if you consented as follows: text first, email second and voicemail last. Once it is successful with one of the methods you consented to the other methods will not be executed.

If you do not consent to one of the above contact methods you understand you will not receive notification(s) of upcoming appointments and will be subject to the No Show/Late Cancellation Policy as listed below. If you do not consent to email notifications, you will not receive any administrative announcements (ie. notification of office closings or changes), from Healthcare Provider and any amounts not covered under the insurance (if applicable) will be your responsibility and billings will be sent to the mailing address on file for the above-mentioned patient.
No Show and Late Cancellation Policy Effective January 1, 2018
Each client is forgiven for one missed/no show appointment. If the client misses a subsequent appointment, or does not cancel an appointment within twelve (24) hours of their scheduled appointment time they will be charged a fee of $30 for each subsequent appointment missed. The individual client will receive a bill in the mail from Community Health Partners. Services cannot continue with our clinicians until the balance owed has been paid in full. Clients with three or more no-shows will be discharged from the practice for one year.
Printed Name of Responsible Party
Emotional Wellness Telehealth Informed Consent Form
Patient or Parent/Guardian Name
4) I understand that I may benefit from telehealth services, but that results cannot be guaranteed or assured. I understand that the use of Advanced MD Telehealth platform audio/video systems are not 100% secure and may have issues with Wi-Fi connectivity. All attempts to keep information confidential while using these systems will be made but a guarantee of 100% confidentiality cannot be made with inherent issues with these communication systems. Signing this form shows an awareness of these issues and a decision by this client to use these systems for telehealth services. I will not hold Emotional Wellness Department of Community Health Partners (CHP) or its staff liable for gathering or use of client information by these service providers.

5) I understand I have the right to access my personal information and copies of case notes. I have read and understand the information provided above. I have discussed these points with my therapist, and all of my questions regarding the above matters have been answered to my approval.

6) By signing this document, I agree that certain situations including emergencies and crises are inappropriate for audio/video/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or go to the nearest hospital or crisis facility. By signing this document, I understand that emergency situation may include thoughts about hurting or harming myself or others, having uncontrolled psychotic symptoms, if I am in a life threating or emergency situation, and/or if I am abusing drugs or alcohol and are not safe. By signing this document, I acknowledge I have been told that if I feel suicidal, I am to call 911, local county crisis agencies or the National Suicide Hotline at 1-800-784-2433.

Signature of client/parent/guardian
Signature

Clear
Date

MonthDayYear
Date
Printed name of client/parent/guardian
Relationship (If applicable)
Joint Notice of Privacy Practices
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. In accordance with the Health Insurance Portability and Accountability Act (HIPPA) and Florida Statute 394, this Notice applies to all sites owned and/or leased by Community Health Partners (CHP) where protected health information is created and maintained. Definition: Protected Health Information (PHI) refers to all the information created and maintained

(whether oral, written, electronic, magnetic or recorded in any form) by CHP when a member receives treatment or services. General Rule: In certain circumstances we may use and disclose your PHI without your written consent.

Examples of disclosures include:
- For Treatment- CHP may disclose information to past and future providers within CHP and to your CHP team for the purpose of coordinating the service you receive. CHP may also provide information to contracted providers who provide services you receive during your treatment. CHP will share information with your current healthcare providers outside of CHP if you offer the name and address of these providers and sign a release of information.
- For Payment- CHP will use and disclose your PHI to send bills and collect payment from you, your insurance company, and other payers for the care, treatment, and other related services you receive. Your PHI may also be submitted to business associate collection agencies as needed to secure payment for your service.
- For Health Care Operations- PHI may be disclosed to Florida and Federal regulatory agencies and licensing authorities.
Your PHI may also be used or disclosed without your authorization or written consent as follows:
- When required by Federal law and Florida Statutes
- When a serious and imminent threat to the health and safety of a person or the public has been made
- When threats concerning the well-being of the President of the United States have been made
- When research and development for educational purposes is being conducted
- When a court order has been issued
- When there is abuse, neglect, exploitation, domestic violence or criminal activity
- To contact you with an appointment reminder or to communicate information about your appointment Other uses and disclosures of your PHI, including psychotherapy notes, will occur only with your written authorization. You may revoke authorization in writing at any time. CHP will make reasonable efforts to use or disclose the minimum amount of PHI necessary to accomplish the intended purpose.
EMOTIONAL WELLNESS
NO SHOW AND LATE CANCELLATION POLICY

Each client is forgiven for one missed/no show on an appointment. If the client misses a second appointment, or does not cancel an appointment within twenty-four (24) hours of their scheduled appointment they will be charged a fee of $30. The individual client will receive a bill in the mail from Community Health Partners. Services cannot continue to be provided until the balance owed has been paid in full. Clients with three or more no-shows will be discharged from the practice for one year. Please be aware that clients can leave a confidential voicemail on 239-659-7751 or a confidential email to ew@chealthpartners.com and this will be sufficient notification.
Child/Adolescent Intake Form
Name
Date

MonthDayYear
Date
Describe the problem that brought you here today
Please check all your child’s behaviors and symptoms that you consider problematic

DistractibilityChange in appetiteVisual hallucinationsManipulative behaviorHyperactivityWithdrawal from peopleDefianceNo/few friendsImpulsivityAnxiety/worryAggression/fightsEating problemsBoredomPanic attacksHomicidal thoughtsSleep problemsPoor memory/confusionFear away from homeFrequent argumentsNightmaresSadness/depressionSocial discomfortIrritability/angerToileting problemsHopelessnessPhobiasPeer/sibling conflictFire settingThoughts of deathObsessive thoughtsStealingWork/school problemsSelf-harm behaviorsCompulsive behaviorDestroys propertyLegal problemsCrying spellsRacing thoughtsRunning awaySexual behaviorLonelinessWide mood swingsSwearingComputer addictionLow self worthSuspicion/paranoiaCurfew violationsAlcohol/drug useFatigueHearing voicesLyingLack of motivationRecurring, disturbing memoriesOther
Are your child’s problems affecting any of the following?

Handling everyday tasksSelf esteemRelationshipsHygieneHealthRecreational activitiesWork/SchoolHousingLegal mattersFinances
Has your child ever had thoughts, made statements, or attempted to hurt him/herself?

NoYes
If yes, please describe:
Has you child ever had thoughts, made statements, or attempted to hurt him/herself?

YesNo
If yes, please describe:
Has your child recently been physically hurt or threatened by someone else?

YesNo
If so, please describe:
Has your child gambled in the past 6 months? If yes, let us know the following

YesNo
Has your child ever felt the need to bet more and more money?

YesNo
Has your child ever had to lie to people about how much your child has gambled?

YesNo
FAMILY AND DEVELOPMENTAL HISTORY

Family Relationships

	Name	Lives With Child?	Age	Quality of Relationship
Mother
Father
Stepmother
Stepfather
Siblings
Other Relatives
Other Relatives
Other Relatives
Other Relatives
Other Relatives

Family/Mental Health Problems

	Who?
Hyperactivity
Sexually Abused
Depression
Manic Depression
Suicide
Anxiety
Panic Attacks
Obsessive-Compulsive
Anger/Abusive
Schizophrenia
Eating Disorder
Alcohol Abuse
Drug Abuse

Family Status

Parents legally married or living togetherParents temporarily separatedFather RemarriedParents divorced or permanently separatedNumber of times mother and/or father remarried
Please check if your child has experienced any of the following types of trauma or loss:

Emotional abuseNeglectLived in a foster homeSexual abuseViolence in the homeMultiple family movesPhysical abuseCrime victimHomelessnessParent substance abuseParent illnessLoss of a loved oneTeen pregnancyPlaced a child for adoptionFinancial problems
Were there any medical problems during the pregnancy or birth of your child? If yes, please describe:
Did the biological mother use any tobacco, medication, street drugs or alchohol while pregnant with this child?

YesNo
If yes, please describe substances used, quantity, and frequency.
Did your child have any developmental delays in early childhood crawling, walking, talking, toileting, etc? If yes, please describe

YesNo Did your child have any developmental delays in early childhood crawling, walking, talking,
If yes, please describe
PREVIOUS MENTAL HEALTH TREATMENT

Type a question

	Yes	No	When?	Provider/Program
Outpatient Counseling
Medication (Mental Health)
Psychiatric Hospitalization
Drug/Alcohol Treatment
Self-Help/Support Groups
Outpatient Counseling

Current grade/placement
This year's school grades

ExcellentGoodFairPoor
Past School Grades:

ExcellentGoodFairPoor
This year's school behavior:

ExcellentGoodFairPoor
This year's school behavior:

ExcellentGoodFairPoor
Has your child had any of the following difficulties at school?

SuspensionIncomplete homeworkLearning problemsReferrals or detentionsPoor gradesTeased or picked onSpeech problemsAttendance problemsGang influence
Does your child have an after-school provider?

YesNo
If so, who?
Has your child ever repeated or skipped a grade?

YesNo
If yes, which one(s)?
Has your child ever received Special Education services?

YesNo
If yes, please describe services received and reason for services.
What does your child’s teacher(s) say about him/her?
SUBSTANCE USE HISTORY (for ages 12 and older or if applicable)

	Y	N	Frequency	Amount	Y	N	Frequency	Amount
Tobacco
Caffeine
Marijuana
Cocaine/crack
Ecstasy
Heroin
Inhalants
Methamphetamines
Pain Killers
PCP/LSD
Steroids
Tranquilizers
Alcohol

Has your child had withdrawal symptoms when trying to stop using any substances?

YesNo
If yes, please describe
Has your child ever had problems with work, relationships, health, the law, etc. due to his/hersubstance use?

YesNo
If yes, please describe
MEDICAL INFORMATION
Date of last physical exam

MonthDayYear
Date
Has your child experienced any of the following medical conditions during his/her lifetime?

AllergiesAsthmaHeadachesStomach achesChronic painSurgerySerious accidentHead injuryDizziness/faintingMeningitisSeizuresVision problemsHigh feversDiabetesHearing problemsEar infectionsMiscarriageAbortionSleep disorderSexually transmitted diseaseOther
Please list any CURRENT health concerns
Current prescription medications

I have no prescriptionsI am currently on prescription medications (see below)

Current prescription medications

	Medication	Dosage	Date First Prescribed	Prescribed By
Current
Current
Current

Current over-the-counter medications including vitamins, herbal remedies, etc
Allergies and/or adverse reactions to medications

No AllergiesYes, I do have allergies (see below)
Allergies and/or adverse reactions to medications:
INTERPERSONAL/SOCIAL/CULTURAL INFORMATION
Please describe your child’s social support network (check all that apply)

FamilyNeighborsFriendsStudentsCo-workersSupport/Self-Help GroupCommunity GroupReligious/Spiritual Center
To which cultural or ethnic group does your child belong?
If your child is experiencing any difficulties due to cultural or ethnic issues, please describe
How important are spiritual matters to your child?

Not at allLittleSomewhatVery much
Would you like spiritual/religious beliefs to be incorporated into your child’s counseling?

YesNo
Please describe your child’s strengths, skills, and talents
Describe any special areas of interest or hobbies art, books, physical fitness, etc
LEGAL INFORMATION
If the parents are separated or divorced, what is the current child custody/visitation arrangement?
Is your child currently the subject of a custody case?

YesNo
Has your child ever been a ward of the court with SCF/DCFS guardianship?

YesNo
Does your child have any legal offenses on record or pending in the courts?

YesNo
By signing below, you are acknowledging and consenting to all information, practices and policies listed above. By submitting this form you acknowledge and consent to this information being securely transmitted to your assigned provider.

Clear
Should be Empty:

Adolescent/Child Intake Packet

General Authorization For Treatment

Rights of Person Served

PHONE/EMAIL CONTACT CONSENT AND AUTHORIZATION

For The Emotional Wellness Program

EMAILS OR WORK PHONE NUMBERS

No Show and Late Cancellation Policy Effective January 1, 2018

Emotional Wellness Telehealth Informed Consent Form

Joint Notice of Privacy Practices

EMOTIONAL WELLNESS

Child/Adolescent Intake Form

FAMILY AND DEVELOPMENTAL HISTORY

PREVIOUS MENTAL HEALTH TREATMENT

MEDICAL INFORMATION

INTERPERSONAL/SOCIAL/CULTURAL INFORMATION

LEGAL INFORMATION