Child/Adolescent Information Form

Child/Adolescent Information Form
Patient Name*

TitleFirst NameMiddle NameLast NameSuffix
Preferred Name
Patient Gender*
Patient Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Work Phone
Cell Phone
Patient E-Mail*
Receive appointment reminders via e-mail?*
Receive invoices/statements via e-mail?*
e-mail for invoices (if different)
Dr. Koch does not directly bill insurance companies. Will you be submitting statements of service to your insurance for reimbursement?
Are you a full-time student
Name of school
Are you employed?
Employer
Occupation (if applicable)

For patients 17 years of age and younger:
Relationship to patient
List other relationship
Parent's/Guardian's Name

TitleFirst NameMiddle NameLast Name
Parent's/Gaurdian's e-Mail
Parent's/Guardian's Phone
Do you live with patient
Address

Street Address

Street Address Line 2

CityState

Zip Code
Relationship to patient
List other relationship
2nd Parent's/2nd Guardian's Name

TitleFirst NameMiddle NameLast Name
2nd Parent's/2nd Guardian's e-Mail
2nd Parent's/2nd Guardian's Phone
Do you live with patient
Address

Street Address

Street Address Line 2

CityState

Zip Code

Treatment Concerns and Goals
Current Concerns
What concerns are you currently having? What brings you to the office now rather than before?
Treatment Goals
What changes would you like to see in your life? What are your goals for treatment?
Previous Treatment
Have you previously been in therapy or seen a psychiatrist before? How successful was it or how satisfied with the services were you? How would you like this experience to be different?

General Background/Demographics
Where were you born?
How long have you lives in the Nashville area?
Who lives with you?
Legal History
Religious affiliation (if any)/Spiritual
Legal History
Additional Information

Substance Use History

Past or Present Substance Use (age of first use, frequency of use, amount used, last use, etc.):
Do you drink caffeine?
Pattern
Age of first use, frequency of use, amount used, etc.
Do you use tobacco/nicotine in any form?
Pattern
Age of first use, frequency of use, amount used, etc.
Last use:
Do you drink alcohol?
Pattern
Age of first use, frequency of use, amount used, etc.
Last use:
Do you use Marijuana?
Pattern
Age of first use, frequency of use, amount used, etc.
Last use:
Do you use Cocaine, Methamphetamine, or other stimulants (not prescribed to you)?
Pattern
Age of first use, frequency of use, amount used, etc.
Last use:
Do you use anti-anxiety medications (benzodiazepines, barbiturates, etc.)?
Pattern
Prescribed to you or not? Age of first use, frequency of use, amount used, etc.
Last use:
Do you use narcotic/opiate pain medications?
Pattern
Prescribed to you or not? Age of first use, frequency of use, amount used, etc.
Last use:
Do you use inhalants?
Pattern
Age of first use, frequency of use, amount used, last use, etc.
Last use:
Other Drug Use?
Pattern
Age of first use, frequency of use, amount used, last use, etc.
Last use:

Family Psychiatric History

Family mental health history (who has had or is suspected of having had what illnesses and did they receive treatment? e.g.: grandmother with depression treated with Prozac):
Mother's side:
Father's side:
Siblings:
Children:
Family Medical History
List any significant family medical illnesses or history (including neurological illnesses like Parkinson’s, seizures, diabetes, thyroid/endocrine, cardiac/heart attacks) in family members:

Patient Care

Thank you for choosing me to provide your psychiatric care. I strive to provide outpatient mental health services; including evaluation, diagnosis, education, and treatment; for children, adolescents, and adults. My treatment approach is individualized for each patient in order to address psychoeducational, psychotherapeutic, and/or pharmacologic management needs.

Although I do not have an inpatient practice, should you require admission to a hospital or residential setting, I will assist you in making appropriate arrangements, readily communicate with inpatient providers, and resume outpatient treatment at the time of discharge.

Appointments

The nature of outpatient psychiatric care requires an initial evaluation and subsequent follow-up visits as scheduled appointments. Follow up appointments are typically 25 or 45 minutes in duration and a full business day (24 hours Monday through Friday) notice of cancellation is required. Appointments that are missed or are canceled less than one business day in advance charge will be charged the full appointment charge.

If you anticipate not being able to make it to your scheduled appointment, please notify the office with as much advanced notice as possible. Please note: appointments scheduled and not kept will be billed to you and insurance companies will not reimburse for any portion of missed appointments.

If you have a regularly scheduled appointment and must cancel, I will assume that you intend to keep your next regularly scheduled appointment unless you notify the office otherwise

Fees & Insurance

Although I am not a participating provider for any insurance networks, I am happy to provide a statement of service that you may file with your insurance provider. Please remember that your insurance is to reimburse you directly for the services provided. The fee for your child’s initial evaluation is $350 and is due at the time of service. Payment may be made by cash, check, or credit card (Visa or Mastercard).

Statements are generally sent out at the end of each week. If you will be submitting the visits to your insurance provider for reimbursement, please let the office know in order to make sure the statements will contain the information needed to submit the claim. Insurance forms are generally available from your health insurance carrier or employer.

Prescriptions

New prescriptions and refills should be obtained at the time of regularly scheduled visit. If you do require a refill between sessions, please check with your pharmacy to see if refills have already been authorized. If no refills are available, please call the office Monday through Friday from 9:00am to 4:00pm. As Dr. Koch is not always in the office to provide refills, please know that it may be three or four days before the requested prescriptions are available. The office will notify you when the prescription is ready and there is a $10 charge for refills provided outside of regularly scheduled follow-up visits.

As some pharmacies fax automated refill requests, please request your pharmacy disable these automated reminders. In order to avoid inadvertent charges for refill requests, faxed prescription refill authorizations received from pharmacies are generally ignored unless the office has received advanced notification from you that the refill is, indeed, needed.

Emergencies

In the event of an emergency (a situation which requiring immediate attention due to concerns of for an imminent danger to self or others), please call 911 or go to your local emergency room/department. Please ask the physician to contact me directly as appropriate. NOTE: after 4pm Monday through Friday and on weekends, there are no staff to accept telephone calls. Messages can be left on my emergency voicemail that will attempt to page me directly. If for any reason during an emergency situation you are unable to reach me, you should go directly to the nearest emergency room. Hospitals providing emergency psychiatric assessment:

Vanderbilt (Respond): (615) 327-7000
Parthenon Pavilion (Options): (615) 342-1400 Rolling Hills Hospital (Respond): (800) 832-0388

Non-urgent Communication

If you need to speak with me between appointments, please leave a message with the office at (615) 515-7775. As I may not be immediately available, please leave both daytime and nighttime numbers so that I may best return your call. I will make every effort to return calls on the same day that messages are left.

Confidentiality

With your consent, the office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes are:
Staff obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor may determine that you need an EKG, medical procedure, laboratory test, or emergency evaluation. He/she will share information with the doctor, or assistant, in order to get your tests completed or to permit emergency care in the case of an emergency assessment.

Examples of uses of your health information for payment purposes:
Submission of information for payment to your health insurance company. The health insurance company or business associate helping us obtains payment requests information from us regarding your medical care given. We will provide information to them about you and the care given.

Examples of uses of your health information for health care operations:
We may obtain services from business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, billing services, mailing services, and insurance.

Additional information is available on the website:drjackkoch.com and in the office policies.
Assignment and Release
Person responsible for payment:*

PrefixFirst NameMiddle NameLast NameSuffix
Relationship to patient:
E-mail*
Phone Number*
I hereby authorize Jack L. Koch Jr., M.D. to provide treatment for my child and agree to assume full responsibility for fees for these services.

Should it become necessary, I authorize Jack L. Koch Jr., M.D. to release and exchange in verbal and/or written form any information necessary for the payment of fees, and/or the provision of my medical care. This may include information related to alcohol or substance abuse.

By signing this form, you hereby agree to pay your account within 45 days following the date of the payment invoice. Should you fail to pay your account in a timely manner, you will also pay on demand late charges and any amount incurred in collecting, enforcing, or protecting the Provider’s rights under this agreement. These expenses will bear interest from the date payment is due until paid in full at the interest rate permissible by Tennessee law in effect at the signing of this document. This amount may include, but is not limited to attorneys’ fees, court costs, and other legal expenses incurred at all stages of collection.

If the person responsible for payment will not be present at the time of the initial visit, please have them provide credit card information to the receptionist prior to the initial evaluation date.

I have read this form in full and have received a copy of Jack L. Koch Jr., M.D.’s office policy. I agree to assume full responsibility for the fees for the services provided.
Responsible Party Signature (by entering my name and the date in the fields below, I agree to the above):*

First NameMiddle NameLast Name
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

	Yes	No	Current	Past
Abnormal Bleeding/Bruising
Alcohol/Substance Abuse/Dependence
Allergies
Anemia
Angina Pectoris
Artificial Heart Valve
Asthma
Congenital Heart Defect
Diabetes
Emphysema
Epilepsy/Seizures
Fainting Spells
Frequent Headaches
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pace Maker
Rheumatic Fever
Sexually Transmitted Disease
Shingles
Sickle Cell Disease
Stroke
Thyroid Problems
Tuberculosis

	Yes	No
Are you taking birth control pills?
Are you planning on becoming pregnant?
Are you pregnant?
Are you nursing?

Child/Adolescent Information Form

For patients 17 years of age and younger:

Treatment Concerns and Goals

General Background/Demographics

Medical History

Substance Use History

Family Psychiatric History

Assignment and Release