Bismarck Locationminot Location

Bismarck LocationMinot Location

2625 N 19th Street601 18th Ave SE Suite 201

Bismarck, North Dakota 58503Minot, ND 58701

phone: 701-222-3175Phone: 701-852-4230

fax: 701-222-3186Fax: 701-838-2572Counseling Services Intake Form (Child)

Our evaluation of your child will depend on information about his/her past history. Fill out this form as completely as possible and bring with you the day of the evaluation. If you have questions regarding any items, put a checkmark in the left margin and we can discuss them when you come for your appointment.

Today’s date:

Person completing form (first/last name):

Relationship to child:

If you are not the child’s current legal guardian, please list the legal guardian:

Type(s) of service desired:

❏Child therapy

❏Adolescent therapy

❏Family therapy

IDENTIFICATION:

Name:
Gender:
Date of birth:
Age:
Ethnicity:
Child lives with:
Primary address:
City, State, Zip
Telephone: / Home:
Work:
Cell:
Parent email:

Referred by :

❏Parent/guardian

❏Pediatrician

❏School

❏EAP

❏CPS

❏Social Services

❏Court Order

❏Other: ______

Emergency Contact name:
Emergency Contact number:
Relationship:

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Consent for Child Treatment

I am the legal guardian of ______with full legal authority to consent to treatment. I give permission for Red Door Pediatric Therapy Counselors to provide treatment for this child which may include assessment advocacy, referral and mental health counseling.

Signature: ______Date:______

Print name:______Relationship to child:______

Section 1: Reason for the Assessment

Child's main problem/major reason for seeking help at this time:

How long has your child had these problems, symptoms, or issues?

Has your child had treatment for these issues in the past?

❏Yes, if so, was the outcome helpful?

❏No

Has your child had inpatient mental health treatment?

❏Yes

❏No

Briefly describe treatment including dates, name of facility/therapist, presenting issues and outcome:

Describe any other behavioral or emotional problems your child is having:

Describe the impact of your child's problems on the family:

Describe your child's strengths and unique qualities:

Does this child have a history of abuse (physical, sexual, emotional, neglect)?

❏Yes

❏No

Is there any other legal action that may have impacted your child? Please check all that apply:

❏Custody

❏Probation

❏Visitation

❏Adoption

❏Child Protective Services

Section 2: Family Information

List all of the people who currently live with the child.

Name / Age / Relationship / Occupation/School

Indicate if any family members have the following:

Father / Mother / Brother / Sister
Attention, activity or impulse control as a child
Learning disabilities
Alcohol/Drug Abuse
Problems with aggressive behavior as an adult or child
Legal Issues
Abuse victim
Depression/Anxiety
Other Mental Health Issues
Serious illness
Surgeries
Physical disabilities

Family Stresses:

Check all that apply:

Topic / Current / In the past
Marital problems
Marital separation
Divorce
Legal issues
Financial problems
Job loss
Custody disputes
Housing Issues
Death of a pet
Death of a friend
Death of a relative
Family illness
Parent(s) using alcohol/drugs

Other stressors: If other stressors, please describe:

What are your family supports? (church, friends, clubs etc.)

What are your family strengths?

Additional comments:

Section 3: Behavioral Assessment

Please check any of the following behaviors that concern you:

Behavior / Currently / In the past
Sadness
Depression
Temper outbursts
Loss of enjoyment of usual activities
Withdrawn
Irritability
Anger
Expressing a wish to die
Has threatened/attempted suicide
Injures self
Disobedience/Refuses to Listen
Bedtime fears
Won't sleep/Trouble going to sleep
Sleepwalking
Nightmares
Night terrors
Wakes up very early
Unable to go back to sleep
Tiredness
Fatigue
Restless sleep
Wakes frequently
Sleeps too much
Does things that annoy others
Worries more than others
Unusual fears or phobias
Panics/Anxious
Repeats unnecessary act over and over
Is overly concerned about things
Has rituals, habits, superstitions, obsessions
Twitches or unusual movements
Eats very little/fasts to lose weight
Gorges or binge eats
Easily annoyed by others
Blames other for own mistakes
Swears or uses obscene language
Low self-esteem
Wanting to run away
Sneaks out at night
Stealing
Lying
Hurts animals
Poor appetite
Destroys property
Hurts people
Overly active
Frequently acts without thinking
Doesn't finish things
Short attention span
Problems with authority
Daydreams
Fantasizes
Problems with the law
Easily distracted
Low motivation
Hallucinations
Vomits intentionally
Bedwetting/daytime wetting
Soiling (pooping) in pants
Strange or unusual behavioral
Disorientation

Forms of discipline used in the home: please check all that apply

❏Time out

❏Loss of privileges

❏Grounding

❏Rewards/incentives

❏Extra chores

❏Physical/corporal punishment

❏Other:

Section 4: Developmental History

During pregnancy, did mother:

❏drink/use drugs

❏illnesses

❏accident

❏problems with pregnancy

❏problems with labor

❏problems with delivery If yes, please describe:

Please check if child is/was delayed in any of the following areas:

❏holding head up

❏turning over

❏sitting up

❏crawling

❏walking alone

❏weaning

❏feeding self

❏toilet training

❏using single words

❏using sentences

❏dressing self

❏sleeping through night

As a baby/toddler, was child:

❏eating well

❏colicky

❏head banging

❏performing rocking behavior

❏clumsy

❏easy to regulate (sleeping/eating)

❏wanting to be left alone

❏adaptable to transitions

❏more interested in things than people

❏easy to soothe

❏performing daredevil behavior

Social/Relationship Development:

Please check each item that applies:

Behavior / Current / In the past
Prefers to be alone
Is demanding and bossy
Is alone a lot, but dislikes this and feels lonely
Fights with others
Is shy
Bullies others
Has few friends
Teases a lot
Has many friends
Plays with younger kids
Plays with “problem kids”
Plays with older kids
Is picked on a lot
Poor relationships with peers
Is oversensitive
Conflict with parents/step-parents
Poor relationships with teachers
Has difficulty getting along with brothers and sisters

School Related Topics:

Your child’s school:

Grade:

Teacher:

Please check any area of concern:

Behavior / Current / In the Past
Dislikes school
Missed many school days
Works hard but does not do well
Repeated a grade
Unmotivated
Refuses to complete work
Discipline referrals
Detentions
Learning problems
Suspensions, if so how many? ______
Expulsions, if so how many? ______

School Environment:

Check all that apply:

Programs / Current / In the past
Resource classes/special ed.
Continuation school
Gifted program
Home study
Speech therapy
Occupational therapy
Independent study

Other:

Section 5: Medical History

PHYSICIAN INFORMATION:

Child’s Primary Doctor:

Indicate if your child has had any of the following:

Condition / Y/N / Details
Migraines/Headaches
Hormone-related problems
Head injuries
Loss of consciousness/dizzy
Heart Issues
Seizures
Kidney-related Issues
Allergies
Diabetes
Asthma
HIV/AIDS
Cancer
Hospitalizations
Surgeries

Does your child have any other medical conditions? { } Yes { } No

If yes, please describe:

Does your child frequently complain of bodily aches and pains? { } Yes { } No

If yes, please describe:

Does your child miss school because of his/her physical complaints? { } Yes { } No

If yes, please describe:

Does your child have any allergies to medications, drugs or foods? { } Yes { } No

If yes, please describe:

Is your child currently taking any medications?

❏ Yes, if yes, include the following information: Name of medications Dosage Prescribed by whom

Name of medication / Dosage / Prescribing physician

Section 6: Insurance Information

Primary coverage:

Patient name:
Policyholder:
Policy ID number:
Group number:
Insurance provider number:
Insurance Company Name:
Address:
Phone Number:

Secondary coverage, if applicable:

Patient name:
Policyholder:
Policy ID number:
Group number:
Insurance provider number:
Insurance Company Name:
Address:
Phone Number:

I hereby acknowledge that the information provided above is accurate and current:

Signature______Date:______

Patient Name______Date:______

Notice of Policies and Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Introduction: This notice describes how Red Door Pediatric Therapy handles information about your—how information is used in the office, how information might be shared with other professionals and organizations, and how that information can have accessed. It is important to understand these policies so that the best decisions for you and your family can be made about personal and medical health information. It is a requirement to provide this information to you as a result of privacy regulations of a federal law and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Each time there is a visit by any healthcare provider, information is collected about your physical and mental health. The information is called, according to HIPAA, Protected Health Information (PHI). This information goes into a healthcare record within our office. This information is likely to include the following:

●Past history: childhood, school, work and marital history

●Reason for seeking treatment

●Diagnosis/diagnoses

●Progress notes

●Records from other practitioners treating your child

●Legal matters

●Insurance and billing information

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

●“PHI” refers to information in your health record that could identify you.

●“Treatment, Payment and Health Care Operations” (TPO)

○Treatment is when we provide, coordinate or manage health care and other services related to your health care. An example of treatment would be consulting with another health care provider, such as family physician or another therapist.

○Payment is obtained reimbursement for your health care. We may disclose PHI to the health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

○Health Care Operations are activities that relate to the performance and operation of this practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

●“Use” applies only to activities within the office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

●“Disclosure” applies to activities outside of this office such as releasing, transferring, or providing access to information about you to others.

●“Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form

II. Other Uses and Disclosures Requiring Authorization

We may use or disclose PHI for other purposes than treatment, payment, or health care operations(TPO) when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. You will revoke all such authorizations (of PHI) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures Not Requiring Consent or Authorization

We may use or disclose PHI without your consent or authorization in the following circumstances:

●Child Abuse – If I have reasonable cause to suspect or believe that any child under the age of eighteen years (1) has been abused or neglected, (2) has had non-accidental physical injury, or injury which isn’t consistent with the history given of the injury, or (3) is placed at imminent risk of serious harm, then we are required by law to report this suspicion or belief to the appropriate authority.

●Adult and Domestic Abuse – If we know or in good faith suspect that an elderly individual or an individual, who is disabled or incompetent, has been abused, we may disclose the appropriate information as permitted by law.

●Health Oversight Activities – If a professional oversight organization is investigating this practice, they may subpoena records relevant to such investigation.

●Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records, this information is privileged under state law, and we will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

●Serious Threat to Health or Safety – If we believe in good faith that there is risk of imminent personal injury to you or to other individuals or risk of imminent injury to the property of other individuals, we may disclose the appropriate information as permitted by law.

●Worker’s Compensation – We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s 4 of 5 compensation or other similar programs, established by law, that provide benefits for work related injuries or illness without regard to fault.

IV. Client’s Rights and Therapist’s Duties Client’s Rights:

Patient Rights

●Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.

●Right to Receive Confidential Communications by Alternative Means and at Alternative Location – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are attending this clinic. On your request, we will send your bills to another address.)

●Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in our health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.

●Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

●Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, we will discuss with you the details of the accounting process.

●Right to a Paper Copy – You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.

●Therapist’s Duties: We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. 5 of 5.

●We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.

●If we revise our policies and procedures, we will notify you by U.S. mail or in person during our session. When information is disclosed, we will disclose the minimum amount of information necessary to address the reason the information was requested.

V. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Heather Arnt or Kelli Ellenbaum. They can be reached at 701-222-3175. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The Privacy Officer can provide you with the appropriate address upon request.

VI. Effective Date

This notice will go into effect on September 15, 2009.

Summary Notice of HIPPA Privacy Practices

We may share your health information to: treat you, get paid, run the clinic, tell you aout other health benefits/services, raise funds, tell family and friends about you, do research, health and safety reasons, military purposes, workman’s comp requests, lawsuits, law enforcement, national security reasons, coroner, medical examiner or funeral director use.

YOU HAVE THE RIGHT TO: get a copy of your medical record, change your medical record if you think it is wrong, get a list of whom we share your health information with, ask us to limit the information we share, ask for a copy of our privacy notice, and complain in writing to the clinic if you believe your privacy rights have been violated.

INDIVIDUAL AUTHORIZATION FOR USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your written authorization before we may use or disclose your protected health information for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information may be used or disclosed. Please read the information below carefully before signing this form.

Signature: ______Date:______

Parent/Guardian/Legal representative of Patient:

______Date:______

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