Child Intake Form 2025

General Authorization For Treatment

 

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.

 

Rights of Person Served

You are in partnership with Community Health Partners when receiving services.

Your rights are as follows:

• 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

Your responsibilities are:

• 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
• 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

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.

Emotional Wellness Telehealth Informed Consent Form

I understand I have the following rights with respect to telehealth:

 

1) I have the right to withhold or remove consent at any time without affecting my right to future care ortreatment, nor endangering the loss or withdrawal of any program benefits to which I wouldotherwise be eligible.

2) The laws that protect the confidentiality of my personal information also apply to telehealth. As such,I understand that the information released by me during the course of my sessions is generallyconfidential. There are both mandatory and permissive exceptions to confidentiality including but notlimited to reporting child and vulnerable adult abuse, expressed imminent harm to oneself or others,or as a part of legal proceedings where information is requested by a court of law. I also understandthat the dissemination of any personally identifiable images or information from the telehealthinteraction to other entities shall not occur without my written consent,

3) I understand that there are risks and consequences from telehealth including but not limited to, thepossibility, despite reasonable efforts on the part of Emotional Wellness Department of CommunityHealth Partners (CHP) that: the transmission of my personal information could be disrupted ordistorted by technical failures and/or the transmission of my personal information could beinterrupted by unauthorized persons. In addition, I understand that telehealth-based services and caremay not be as complete and in-person services. I understand that if my therapist believes I would bebettered served by other interventions I will be referred to a mental health professional who canprovide those services in my area. I also understand that there are potential risks and benefitsassociated with any form of mental health treatment, and that despite my efforts and efforts of mytherapist, my condition may not improve, or may have the potential to get worse.

4) I understand I that I may benefit from telehealth services, but that results cannot be 100%  assured. I understand that the use of Advanced MD Telehealth platform audio/video guaranteed are or not confidential secure and may have issues with Wi-Fi connectivity. All attempts to keep information systems be made with while using these systems will be made but a guarantee of 100% confidentiality cannot inherent issues with these communication systems. Signing this form shows will awareness not hold of these issues and a decision by this client to use these systems for telehealth an for Emotional Wellness Department of Community Health Partners (CHP) or its services. staff liable I gathering or use of client information by these service providers.

5) and I understand understand I have the right to access my personal information and copies of case notes. I have all of the information provided above. I have discussed these points with my therapist, read and 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 inappropriate for audio/video/computer-based psychotherapy services. If I am in crisis in are this emergency, document, I should I immediately call 911 or go to the nearest hospital or crisis facility. or By an understand that emergency situation may include thoughts about signing situation, myself or and/or others, having uncontrolled psychotic symptoms, if I am in a life threating hurting emergency or harming if I am abusing drugs or alcohol and are not safe. By signing this or the acknowledge National I have been told that if I feel suicidal, I am to call 911, local county crisis document, agencies I or Suicide Hotline at 1-800-784-2433.

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 inforamtion is created or maintained.

Defintion: 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 disclosure 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 aand 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 requred 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 acccomplish the intended purpose.

I hereby authorize the disclosure of information from Emotional Wellness Department at Community Health Partners to:

I understand that authorizing the disclosure of this information is voluntary. I can refuse to sign this consent and do not need to sign this form in order to receive treatment. I acknowledge that I give authorization to this disclosure as described above. I understand that I have the right to revoke at any time in writing. I understand that revoking this authorization will not this affect actions already taken on it. I understand that I am entitled to receive a copy of this authorization any after request. the Each disclosure requires an additional signed authorization. This consent will expire 180 upon days date of my signing. I hereby agree to hold Community Health Partners and its clinicians with this consent.harmless for any liability that may result directly or indirectly from the disclosure released in accordance

EMOTIONAL WELLNESS EFFECTIVE 10/14/2019

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 $50. 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. 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.

I have been told that, in order to protect the limited confidentiality of records, my agreement to obtain or release information is necessary and that this permission is limited for the purposes and to the person listed above, and will be effective from the date of my signature to a maximum of two years. I may change the contact in this consent at any time. A photocopy or facsimile of this form may be accepted in lieu of the original signed form. I also understand that this consent is revocable except to the extent that action has been taken on it already.

I further understand that the Emotional Wellness Department and its practitioners at Community disclosure. Health Partners will not condition my treatment on whether I give authorization for the requested disclosure.

Court and Legal Fees

Clients are discouraged from having us subpoenaed or having us provide records for the purpose of litigation. Even though you are responsible for the testimony fee, it does not mean that our testimony will be solely in your favor. We can only testify to the facts of the case and to our professional opinion. Furthermore, we need to assess to ensure there are no conflict of interest that could arise from our testimony. We would rather not damage the trust we have built in the counseling relationship with each client, especially if we are still seeing that person(s) for therapy. 

If we are to receive a subpoena, the attorney or office staff will need to call our office and set a time for the subpoena to be served during office hours. We request a minimum of 72 hours notice up of any court appearance so that schedule changes for our clients can be made within a reasonable time frame. Please note: If a subpoena or notice to meet attorney(s) is received without a minimum of 72 hour notice, there will be an additional $250 express charge, which must be paid prior to my appearance in the courtroom.

When it comes to court action, the following fees are in effect (please note that the fee schedule listed below is NOT covered by insurance:

1. Preparation Time (including submission of records): $200/hr (billable in 15 minute increments)

2. Phone calls: $200/hr (billable in 15 minute increments)

3. Depositions: $250/hour

4. Time required in Giving Testimony: $250/hour

5. Mileage: .50/mile

6. All attorney fees and costs that are incurred by me as a result of the legal action.

7. Filing documents with the court: $100 flat fee

8. The minimum charge for a court appearance: $1000

A retainer of $1000 is due at least 72 business hours before the scheduled court appearance. The remainder of the costs will be billed after the court appearance and will be due upon receipt. If we am subpoenaed, and the case is continued with less than 48 business hours notice prior to the beginning of the day of the scheduled court appearance and/or the testimony is not given, then the client will be charged $500 (in addition to original retainer of $1000 for having to appear in court All fees listed above are doubled if the therapist is scheduled to be going out of town. Bills are presented to clients on a weekly basis and payment is expected upon receipt.

I understand the above fee schedule and agree to these terms:

Please complete the information below. Information provided on this form is protected as confidential information.

Treatment History

General and Mental Health Information

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family members relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

 

Child/Adolescent Intake Form

 

PRESENTING PROBLEMS AND CONCERNS

 

PREVIOUS MENTAL HEALTH TREATMENT

Please describe your child's social support network (check all that apply): FamilyFriendsStudents Neighbors Community GroupReligious/Spiritual Center (which one?

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: