SSC Child/Adolescent Registration Form

Child and Adolescent Registration

There are several pages of this form, and in order to submit it, all pages need to be completed. Thank you for trusting us, and we look forward to working with you!
Patient's Information
Patient's Full Name*

First NameLast Name
Patient's preferred name, if different than the above
Patient's Date of Birth*

MonthDayYear
Date
Patient's Gender*
Patient's Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 1 Name*

First NameLast Name
Parent/Guardian 1 Cell Number*
Please enter a valid phone number.
Parent/Guardian 1 Email*
example@example.com
Parent/Guardian 1 Relationship*
Can we text you on the phone number above?*
Can we leave a voicemail on the phone number above in regards to a bill or appointment?*
Preferred form of contact*
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Cell Number
Please enter a valid phone number.
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Relationship
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship*
Patient's Therapist's Name (type N/A if you haven't scheduled yet)*
First appointment date/time (type N/A if you haven't scheduled yet)*
Reason(s) for beginning psychotherapy at this time*

Additional Information
Parents Marital Status*
Please list any details regarding this that you would like the therapist to know:
Primary Care Physician and phone number
Date of most recent medical exam

MonthDayYear
If currently prescribed medication, psychiatrist or prescribing physician and phone number
Patient's school grade*
Patient's school name and location*
Patient's school phone number*
Patient's school contact name, if applicable
Name(s) and phone number(s) of anyone who is part of your child's care team
I.e., school personnel, pediatrician, case worker, CPS worker, previous therapist, probation officer, legal aid, etc.
Please describe any/all psychological and/or psychiatric services your child has received in past (i.e., therapy, medication management, inpatient or outpatient hospitalization, etc), and with whom. If none, type N/A.*
Medication(s), psychiatric or general, taken in the past or in the present
Hospitalizations (or other Medical Services) for surgery, illness, or accident
Has your child/adolescent experienced any of the following recently?*

IllnessStressAccidentDeath of significant personTraumaRelocationSeparation from significant personNone of the aboveOther
If you checked off any of the boxes above, please explain below:

Pregnancy History
Describe the mother's condition during the pregnancy: her health, medications taken, diet, and state of mind. Was a doctor seen regularly?*
How many births before this child? *
Age of mother at child's birth?*
Give details or note anything else that was unusual:
Birth History
Is the child a foster child or an adopted child?*
Give details or note anything else that was unusual:

Home Life
Children are often affected by relationship problems or emotional problems of other people at home. Do these problems occur at home? If so, describe and state your opinion as to whether this affects your child's behavior or learning problems.*
Describe whether the child or any other family members (i.e., father, mother, grandparent/s, aunt/s, uncle/s, cousin/s) have been or are being seen for psychotherapy, counseling, or psychiatry. If so, it is important to list such below:*
What is the primary language spoken in the home?*
Are any other languages spoken at home?
Have there been any major family stresses or changes in the past year (i.e., moving with change of school, divorce, significant illness, death of a family member, etc)? If so, please explain below:*
Do the parents or guardians of this child agree on ways to help the child? Please explain below:*
How is the child disciplined, and by whom?*
Parents or guardians see a lot more of their child than others do. Often, they see good points that only come out at home. What are some of the best things about your child?*
Is there a firearm in the home?*
If yes, does the child/adolescent have access to the firearm in the home?

Other History
Please state if any grades were repeated, and if so, why:
List any special services your child has received at school, or through an outside agency, along with the names of those providers, and when services were provided:
I.e., educational testing, reading/math help in school, outside tutoring, special class placement, occupational therapy, psychological testing, psychiatric consultation, psychotherapy, speech/hearing evaluations, speech therapy, etc.
If your best hopes and wishes for your child were to be achieved in the future, how would he or she be different from now? Please also feel free to list anything that you may have left out below:*

Your Confidentiality and Private Practice Policies
I certify this information is true and correct to the best of my knowledge. I understand that all psychological services are performed under the supervision of Dr. William James, Executive Director of South Shore Counseling and Psychological Services, and Max Benezra, EdM, MA, LMHC-D, Assistant Director of South Shore Counseling and Psychological Services, whom can be contacted directly if needed. I understand that all information that I communicate will be held in strict confidence. I also understand that New York State also mandates certain limits to confidentiality. These laws may obligate my mental health provider to report suspected abuse or neglect, domestic violence and those who pose a danger to themselves or others.

There is a $65.00 fee for a missed/no show appointment or a cancellation with less than a 24-hour notice. If you must cancel or reschedule your child's appointment, whether that be in-person or Telehealth (i.e., Google Meet, or Zoom), please notify the therapist at least 24 hours in advance in order to avoid the $65.00 fee. Once we establish a weekly meeting time, that time is yours, and you are scheduled you moving forward for that day and time (i.e., Monday’s at 9am). Please make sure you take care of paying your co-pay at the time of your appointment before leaving the office, if you have one. If we have to bill you, there will be an extra $15.00 Administration Fee that you will be responsible for paying. I will do my best to notify you of any schedule changes in advance as well. Thank you for your cooperation.
Signature*

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Date*

MonthDayYear
Insurance and Payment Information
Please upload your Insurance Card(s) and Drivers License below.

If you have any issue uploading the documents below, email Jen (JenC@sscpsli.com) with photos of your insurance card(s) and drivers license, and move to the next section.
Upload front of patient's insurance card

Cancelof
Upload back of patient's insurance card

Cancelof
Upload front of parent/guardian's drivers license

Cancelof
Are you paying with insurance, or out-of-pocket/private pay?*
Primary Insurance Company (if paying out-of-pocket, type N/A)*
Primary Insurance ID Number (if paying out-of-pocket, type N/A)*
Primary Insurance Policy Holder Name
Primary Insurance Policy Holder Date of Birth

MonthDayYear
Date
Primary Insurance Policy Holder Phone Number
Patient's Relationship to Policy Holder
Secondary Insurance Company
Secondary Insurance ID Number
Secondary Insurance Policy Holder Name
Secondary Insurance Policy Holder Date of Birth

MonthDayYear
Date
Who is responsible for the bill?*
By signing below, I am confirming that I have inputted my child's insurance information above. If I leave the Primary Insurance section blank, I will be paying for sessions out-of-pocket.

Additionally, by signing below, I certify this information is true and correct to the best of my knowledge. I understand the above statements and I will notify South Shore Counseling and Psychological Services of any changes in my child's health insurance status. If I do not notify South Shore Counseling and Psychological Services of any changes and my insurance does not cover any services rendered, I will be ultimately responsible for any balances owed.
Date*

MonthDayYear
Date
Signature*

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Patient Privacy Policies, Rights and Responsibilities
Patient Privacy Policies

In response to the misuse of Personal Health Information (PHI), the Department of Health and Human Services has established a “Privacy Rule” to help insure that PHI is kept private. This rule was also established in order to provide a standard for health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient in order to carry out treatment, payment, or health care operations.

We want you to know that we respect the privacy of your personal medical records and will take all reasonable measures to secure and protect your privacy. When necessary, we will provide the minimum necessary information to only those we feel are in need of your PHI in order to provide health care that is in your best interest.

We support your full access to your personal medical records. You should be aware that we may have indirect treatment relationships with you that include but are not limited to laboratories, pharmacies, and other medical offices. As such, we may need to disclose PHI for purposes of treatment, payment and/or health care operations. These outside entities do not necessarily need to obtain your consent for these communications.

You have the right to refuse to consent to the use or disclosure of your PHI. The refusal must be made in writing. Under the HIPPA law, we have the right to refuse to treat you if you choose to refuse disclosure of your PHI. This refusal must be made in writing. However, you may not revoke actions that have already been taken which relied on this or a previously signed consent.

You have received a copy of our Patient Privacy Policy electronically. You have the right to review our privacy notice, request restrictions and revoke consent in writing after you have received our privacy notice.

Patient Rights

I have a right to efficient and effective care individualized to my needs. My treatment provider will work with me to develop a treatment plan best suited to me. We will use this plan to help us deal with my problems as quickly and effectively as possible.

I have a right to be treated with dignity and respect. I will be treated with respect at all times. I will report any misconduct by my treatment provider including social invitations, suggestive remarks, or unwanted touching to the Directors of SSCPS and/or the appropriate state agency. I may call the Directors of SSCPS at any time with questions, comments or complaints.

My treatment provider will make every effort to meet with me at our scheduled appointment time. If my treatment provider is late, he or she will extend our session, if I am willing, or we will make other arrangements by mutual agreement.

I have a right to privacy and confidentiality. All records and communications about me will be treated confidentially in compliance with applicable state and federal laws. These laws may obligate my mental health provider to report suspected abuse or neglect, domestic violence and those who pose a danger to themselves or others.

Patient Responsibilities

Scheduled appointments are commitments. I will make every effort to be on time for my appointment(s). I agree to follow the cancellation and fee policy as signed earlier in this packet. If I am late for my appointment, I understand that time will be lost from my session. If I miss an appointment and do not notify my treatment provider at least 24 hours in advance, I understand I will be charged a missed appointment fee.

I am responsible to pay for services received. If I am using insurance to pay for psychotherapy, I am aware my insurance plan typically requires me to pay a co-payment (a dollar amount) or co-insurance (a percentage of my treatment provider's fee) at the time services are provided. My insurance plan may also have a deductible (an initial dollar amount) that is my responsibility. Additionally, certain services may be limited and not covered at all by my insurance plan. I understand I am financially responsible for co-payments, co-insurance, deductibles and all services not covered by my insurance plan. My treatment provider, my managed care and my insurance plan’s representative will help me determine what services my insurance plan covers. Should my balance grow, South Shore Counseling and Psychological Services reserves the right to utilize a collections agency to collect any payments owed. I also am aware that if I have an unpaid balance, my sessions may be suspended in compliance with company policy.

My health is my responsibility. I will contact my treatment provider for any serious situation that arises, even after normal office hours. I will work with my provider to achieve my treatment goals and will advise my treatment provider of changes in my condition.

I have read this list of rights and responsibilities or had them read to me. I understand and agree with them.
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Date*

MonthDayYear
Date

Release of Information Form

Please complete this form if there is any one you would like us to have the ability to speak with about any aspect of your child's care with us: mental health care, financial and insurance information, record keeping, and consultation.
Patient Name

First NameLast Name
I authorize South Shore Counseling and Psychological Services, P.C. and its associated Providers/Clinicians/Administrative Staff to use and disclose my protected health information (including records relating to mental health care) to:
Above, please enter anyone who, besides you, would you like us to communicate with about your healthcare: i.e., physician, psychiatrist, educator, family, therapist, legal personnel, individual seeking the information; please list the person(s) name and relationship(s) to you. I.e., "Jane Doe, Mother," or "Dr. Faisal Rafiq, Psychiatrist."
I authorize information to be released/exchanged regarding my child's:

Mental health treatmentFinancial/Health Insurance informationWritten recordsOther
This authorization for release of information covers the period of healthcare from:

All present, past, and future periodsOther
This medical information may be used by the person(s) I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

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

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

MonthDayYear
Date

Teletherapy Consent Form
Please complete this form if your child is meeting with their therapist virtually, or in the event they decide to meet with their therapist virtually for any number of sessions.

This Informed Consent for Teletherapy contains important information focusing on doing psychotherapy using the phone or the Internet. When you sign this document, it will indicate that you understand the information delineated in this document. The Benefits and risks of teletherapy refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of teletherapy is that the client and clinician can engage in services without being in the same physical location, whether it be to physical or mental disability, or temporary/permanent location change.

Risks to confidentiality: As a therapist I will engage teletherapy only in a secure location allowing for no visual or auditory information to be seen or overheard by others. It is important for you to make sure you find a private place for our session where you will not be interrupted or overheard or distracted. My provider is qualified to practice for clients in New York State at the time of session; sessions must be conducted while you are in New York State.

Issues related to technology: There are many ways that technology issues might impact teletherapy. For example, technology may stop working during a session. It is a legal requirement as a professional in the field of psychotherapy that a HIPAA compliant platform for communication that prevents any others from listening to the session material. Not all platforms have such compliance.

Crisis management and intervention: Teletherapy with clients who are currently in a crisis situation requiring high levels of support and intervention are generally not considered good candidates for such a medium. Should a crisis situation develop, it is necessary that an emergency contact person, who preferably is near your location. This will require a separate form with contact information.

Efficacy: Most research shows that teletherapy is about as effective as in-person psychotherapy, however some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely.

Electronic Communications: Computer or mobile phone with an optical device is used for teletherapy. For billing matters, and other related issues not required by HIPAA regulations you can contact South Shore Counseling at 516 785-0323. Confidentiality of any information communicated by email or text or phone cannot be guaranteed. If an urgent issue arises, the undersigned clinician can be reached by phone. Additionally, we have a 24/7 answering service that will contact either me directly or the director at South Shore Counseling. If, under unlikely circumstances, cannot reach us, you should contact the nearest emergency room or call 911.
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Child and Adolescent Registration

Patient's Information

Additional Information

Pregnancy History

Birth History

Infancy and Early Childhood

Childhood/Adolescent Illness

Home Life

Other History

Your Confidentiality and Private Practice Policies

Insurance and Payment Information

Patient Privacy Policies, Rights and Responsibilities

Release of Information Form

Teletherapy Consent Form