Child/Adolescent New Client Forms

Child/Adolescent New Client Forms
This packet includes the forms listed below for clients under age 18.
Bring these completed forms with you to your first appointment at our office. Since your
therapist may want some additional information, please arrive 5 minutes early. Although
there is no receptionist, any additional forms for you to complete will be on a clipboard
marked with your therapist's name and time of your appointment.
Page 2
Welcome
Pages
3-4
Intake
Asks for contact information, some medical and personal background, and
family history.
Page 5
Office Policies
Provides you with an overview of our general office policies and procedures.
Page 6
Parent Therapist
Agreement
Pages
7-8
Privacy Policies
Information about beginning therapy.
Describes unique aspects of therapy with youth.
Gives you information about how the privacy of your health information is
maintained. These pages are for you to keep.
Page 9
Acknowledgment of
Receipt of Privacy
Policies
Only this page of the Privacy Policies needs to be signed and returned.
Page 10
Consent for
Therapy/Evaluation
Describes how we will work together.
Pages
11- 13
Parent/Guardian
Concerns:
Child/Adolescent Form
or Infant/Toddler Form
Checklist to let us know about your concerns about your Child/Adolescent or
Infant/Toddler. Complete the form based on the age of your child.
Developmental History
Asks for relevant information concerning the development of your child.
Insurance Assignment
and Health Insurance
Managed Care Release
Complete Page 18 and 19 ONLY if our office staff has determined that we
participate with your insurance plan. Please be sure to bring your insurance
card and a photo ID for your therapist to copy at your initial appointment.
At the time of each visit, our office will accept cash, checks, or charge card
payments for your co-pays and deductibles. Page 20 explains your co-pay,
co-insurance, and deductible obligations
Release of Information
Optional form. It allows us to coordinate care with your primary care physician,
your referring physician, or anyone else you would like to keep informed of
your treatment with us. Please complete a separate form for each contact
person, providing the name, address, telephone, and fax number for that
person.
Pages
14-18
Pages
19-21
Page 22
If you bring the completed forms with you to your first appointment, do not complete an extra set in
the office. Please check the clipboard in case your therapist left any additional forms for you to
complete.
intake\formslistminorswebNov14.doc Page 1
Welcome to Associates in Health Psychology. We look forward to helping
you and your family find meaningful solutions to the challenges you face.
Beginning the important work of therapy is often a difficult decision.
Even once your initial appointment has been made, you and your family
may feel both eager to begin as well as somewhat uncomfortable about
coming in for your first meeting with your therapist. We understand.
Many people find the thought of beginning therapy unsettling until they
actually start the process. Then they feel more comfortable. Now that
you’ve taken the first step toward working on some of the areas of
concern in your life, try not to let some initial discomfort keep you and
your family from pursuing what you know will be in your best interest.
Before your first meeting, you might think about what you hope to gain
from therapy and what is most important to you. Then you can discuss
these thoughts with your therapist. Some clients have found that jotting
down notes about what they want to discuss helps them feel more
comfortable.
If you have any questions prior to your appointment, please call our
office or email us. You may leave a message for our office staff or our
therapists 24 hours a day, 7 days a week at 302-428-0205. Our email is:
[email protected]
For directions to our locations, see:
www/AHPDelaware.com/locations.htm. Location information is also
available on our telephone system.
Cordially yours,
The Therapists at
Associates in Health Psychology
Forms05\Intake\WelcomeIntroMinorWebJun14.doc
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
Associates in Health Psychology, LLC
Child & Adolescent
Minor's Name _________________________________________________
(First)
(Middle)
Date ______________
(Last)
Minor’s _____________________________________________
Primary
(Address)
Residence ________________________________________
Home Phone _____________________
Cell Phone _____________________
Minor’s Date of Birth ____________________________________ Age _______
Sex __________
Minor’s Birthplace ____________________________________________________________________________________
Mother's Name _________________________________
Home Phone _________________________
Address _____________________________________
Cell Phone _________________________
_____________________________________
Work Phone _________________________
Mother's Occupation ____________________________________________________________________
Father's Name _________________________________
Home Phone _________________________
Address _____________________________________
Cell Phone _________________________
_____________________________________
Work Phone _________________________
Father's Occupation ____________________________________________________________________
Parents’ Marital Status ___Married
___Divorced
___Separated
___Never Married
Legal Guardian’s Name __________________________
Home Phone ________________________
Address _____________________________________
Cell Phone _________________________
_____________________________________
Work Phone _________________________
Legal Guardian's Occupation ____________________________________________________________
When did symptoms first appear? ______________
Similar symptoms in past? ______________
Referred by _____________________________________________________________________________
Family Doctor ______________________________
Other Doctor(s) _________________________
Minor's Education: Current Grade _________ School __________________________________
Special Education/Tutoring/Support Services? ___________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
FOR OFFICE USE: HA SB SC AD CE SE JF JHC SBJ MK HLS SX HM KP AR MS KTH DU CW LZ
______
DSM-5: _____________________________________________________________________ICD9:______________ ICD10:______________
DSM-5: _____________________________________________________________________ICD9:______________ ICD10:______________
Forms05\Intake\IntakeMinorOct14.doc
AHP, LLC
Name ________________________________________________________________
PAGE 2
(First)
(Middle)
(Last)
List all current medication, condition for which your child takes the medication and the dosage:
Medications /Supplements/Vitamins
Condition
Treated by whom?
Dosage
Allergies:________________________________________________________________________________
_________________________________________________________________________________________
Previous Treatment History
Therapist(s)/ ___________________________________________________________________________
Psychiatrist(s)
(Name)
(Facility/Address)
(Approx. Dates seen)
___________________________________________________________________________
(Name)
(Facility/Address)
(Approx. Dates seen)
Mental Health/
Substance Abuse
Hospitalization __________________________________________________________________________
(Inpatient or (Name of Facility)
(Address)
(Approx. Dates)
Day Treatment)
__________________________________________________________________________
(Name of Facility)
(Address)
(Approx. Dates)
Family Information
Brothers & Sisters (Names)
(Sex) (Age)
(Residence)
If parents are not living together, what is the custody arrangement for this minor?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Forms05\Intake\IntakeMinorOct14.doc
OFFICE POLICIES
In order to prevent misunderstandings about office policies, please read the following:
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are
confidential and may not be revealed to anyone without your written permission, except where disclosure is required by
law or by court order. The law requires disclosure where there is a reasonable suspicion of child abuse, elder abuse or
neglect; where a client presents a danger to self, to others, or to property; is gravely disabled; or is significantly impaired
from drug and/or alcohol use. In these emergency situations, therapists will do whatever they can, within the limits of the
law, to prevent clients from injuring self or others and to ensure that clients receive the proper care. Within AHP,
therapists share on-call responsibilities. All AHP therapists are legally bound to keep disclosed information confidential.
We will maintain client case files for 7 years from the last session date, or until the client becomes 24, whichever is later.
TELEPHONE & EMERGENCY PROCEDURES: If you need to reach your (or your child’s) therapist between
appointments, you may leave a message 24 hours a day, 7 days a week, on his/her voice mail at (302) 428-0205. If your
call is urgent, call (302) 428-0205 and dial extension 9. Inform the office staff or our answering service that your call is
urgent. If it is during office hours and the therapist is available, he/she will call you back. After hours, the on-call
therapist will call you back as soon as possible. If your call is urgent and a therapist does not call you back immediately,
please call the Rockford Center Needs Assessment at (302) 996-5480, Psych Crisis of Christiana Care Health Systems at
(302) 428-2118, the Crisis Intervention Services at (302) 577-2484 or (800) 652-2929, or MeadowWood Hospital at (302)
328-3330. If your call is a life threatening emergency, you should go immediately to the closest hospital or call 911.
PAYMENTS: At each session, payment is expected for any fees due. Missed appointments will be charged to you at the
therapist’s usual and customary rate unless you cancel 24 hours before the scheduled appointment. Monday appointments
must be cancelled by the previous Friday. Telephone conversations, site visits, report writing and/or form completion,
consultation with other professionals, reading records, longer sessions, and/or travel time will be charged at the therapist’s
standard, non-contractual rate. Requests to release your records will be subject to an administrative charge.
LITIGATION LIMITATION: Due to the nature of the therapeutic process, which often involves making a full
disclosure with regard to many matters that may be of a confidential nature, it is agreed that should there be legal
proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc...), neither you nor your
attorneys, nor anyone else acting on your behalf, will call on your (or your child’s) therapist to testify in court or at any
other proceeding, nor will a disclosure of the psychotherapy records be requested.
RECORDING: Video or audio recording of any part of a session by either the therapist or client requires the written
consent of both.
TERMINATION: After the first one or two meetings, the therapist will assess if he/she can be of benefit to you (or your
child). Our therapists accept clients only if, in their opinion, they have the particular skills and experience necessary for
treatment. If at any point the therapist assesses that he/she is not effective in helping a client reach the therapeutic goals,
the therapist will discuss it with you. If appropriate, treatment will end and you will be given referrals to other treatment
providers. You also have the right to terminate services at any time. If you wish to do so, please inform your therapist
directly so the necessary steps may be taken to discharge you from care and close your file. If you do not show up for a
scheduled appointment and your therapist does not have contact with you for 6 weeks, your therapist will assume that you
are terminating services, discharge you from care, and close your file.
I have read the Office Policies. I understand them and agree to abide by them.
_______________________________________________
____________________
____________________________________________________
Signature of Client (or Parent/
Date
Client Name (Print)
Guardian if Minor)
Reviewed during initial meeting: ________________________________________________________________________
forms05\intake\officepoliciesapr14.doc
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
Therapy Agreement between the Parents/Guardians of a Minor and the Therapist
Prior to beginning treatment, it is important for you to understand my approach to child therapy and agree to some
rules about your child’s confidentiality during the course of his/her treatment. The information herein is in addition
to the information contained in the Office Policies and Consent for Treatment. Under HIPAA and my professional
ethics code, I am legally and ethically responsible to provide you with informed consent.
One risk of child therapy involves disagreement among parents and/or disagreement between parents and therapist
regarding the best interests of the child. If such disagreements occur, I will strive to listen carefully so that I can
understand your perspectives and fully explain my perspective. We can resolve such disagreements or we can agree
to disagree, so long as this enables your child’s therapeutic progress. Ultimately, you will decide whether therapy
will continue. If either of you decides that therapy should end, I will honor that decision, however I ask that you
allow me the option of having a few closing sessions to appropriately end the treatment relationship.
Therapy is most effective when a trusting relationship exists between the therapist and the client. Privacy is
especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better
relationship between children and their parents. However, it is often necessary for children to develop a “zone of
privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for
adolescents who are naturally developing a greater sense of independence and autonomy. By signing this agreement,
you will be waiving your right of access to your child’s treatment records.
It is my policy to provide you with general information about treatment status. I will raise issues that may impact
your child either inside or outside the home. If it is necessary to refer your child to another mental health
professional with more specialized skills, I will share that information with you. I will not share with you what your
child has disclosed to me without your child’s consent. I will tell you if your child does not attend sessions.
If your child is an adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact,
alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of
adolescent experimentation, but at other times they may require parental intervention. We must carefully and directly
discuss your feelings and opinions regarding acceptable behavior. If I ever believe that your child is at serious risk of
harming him/herself or another, I will inform you.
Note that such agreement may not prevent a judge from requiring my testimony, even though I will work to prevent
such an event. If I am required to testify, I am ethically bound not to give my opinion about parents’ custody,
visitation suitability or their parenting capacity. If the court appoints a custody evaluator, guardian ad litem, or
parenting coordinator, I will provide information as needed (if appropriate releases are signed or a court order is
provided), but I will not make any recommendation about the final decision. Furthermore, if I am required to appear
as a witness, the party responsible for my participation agrees to reimburse me at the rate of $350.00 per hour for
time spent traveling, preparing reports, testifying, being in attendance, and any other case-related costs.
I have read the Therapy Agreement between the Parents/Guardians of a Minor and the Therapist. I understand
them and agree to abide by them.
_______________________________________________
Signature of Parent/Guardian
_______________________________________________
Signature of Parent/Guardian
____________________
Date
____________________________________________________
Client Name (Print)
____________________
Date
Forms05\Intake\ParentTherapistAgrmtApr14.doc
J-­‐25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803 (302) 428-­‐0205 • Fax: (302) 428-­‐1123 • www.AHPDelaware.com Associates in Health Psychology, LLC
Notice of Privacy Policies & Practices
Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about
you may be used and disclosed and how you can get access to this information. Please review it carefully.
I. Uses and Disclosures for Treatment, Payment, and Healthcare Operations
We may use and disclose your protected health information (PHI) for treatment, payment, and healthcare operations with
your consent. To help clarify these terms, here are some definitions.
A. “PHI” refers to information in your health record that could identify you.
B. “Treatment, Payment and Health Care Operations”
– Treatment is providing, coordinating or managing your health care and other services related to your health
care. For example, we may use PHI to provide counseling to you. Or, we may disclose your PHI to other health care
providers involved in your treatment, such as your family physician or another psychologist.
– Payment is obtaining reimbursement for your healthcare. For example, we will disclose your PHI to your
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 our 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.
C. “Use” applies only to activities within Associates in Health Psychology such as sharing, employing, applying,
utilizing, examining, and analyzing information that identifies you.
D. “Disclosure” applies to activities outside of our practice, such as releasing, transferring, or providing access to
information about you to other parties.
II. Uses and Disclosures Requiring Your Authorization
AHP may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your
appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that
permits only specific disclosures.
A. Psychotherapy Notes: Notes recorded by your therapist documenting the contents of a counseling session with you
("Psychotherapy Notes") will be used only by your therapist and will not otherwise be used or disclosed without your
written authorization. Psychotherapy Notes are given a greater degree of protection than PHI.
B. Other Uses and Disclosures: Uses and disclosures other than those described in Section I. above will only be made
with your authorization. For example, you will need to sign an authorization form before AHP can send PHI to your life
insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) 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; the law provides the insurer the right to contest
the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
Your therapist may use or disclose PHI without your consent or authorization when required or permitted to do so by
law. The most common such disclosures are listed below.
A. Child Abuse: If a therapist knows or in good faith suspects child abuse or neglect, the therapist is required to report
such knowledge or suspicion to the appropriate authority.
B. Adult and Domestic Abuse: If a therapist has reasonable cause to believe that an adult person is infirm or
incapacitated and in need of protective services, the therapist must report such information to the Delaware Department
of Health and Social Services.
C. Health Oversight Activities: If the Division of Professional Regulation is investigating our practice, we must
comply with any subpoenas issued by the Division.
D. 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 thereof, such information is privileged under state law,
and AHP will not release information without the written authorization of you or your legally appointed representative or
Forms05\HIPPAtx\AHPPrivNoticeSep13
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.
E. Serious Threat to Health or Safety: If you communicate to your therapist an explicit and imminent threat to kill or
seriously injure a clearly identified victim or victims, or to commit a specific violent act or to destroy property under
circumstances which could easily lead to serious personal injury or death, and you have an apparent intent and ability to
carry out the threat, the therapist may disclose information in order to provide protection for the identified victim. If your
therapist believes that there is an imminent risk that you will inflict serious physical harm on yourself, the therapist may
disclose information in order to protect you.
F. Privacy Rule Exceptions: When the use and disclosure without your consent or authorization is allowed under other
sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law. This includes certain narrowlydefined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of
health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for
specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and
intelligence.
IV. Your Rights
A. Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket. You have the right to restrict
certain disclosures of PHI to a health plan when you pay out-of-pocket in full for AHP services.
B. Right to Request Other Restrictions: You have the right to request other restrictions on certain uses and
disclosures of protected health information. However, AHP is not required to agree to your request.
C Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: 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 seeing a therapist.) On your request, we will
send your bills to another address.
D. Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in the AHP mental
health and billing records used to make decisions about you for as long as the PHI is maintained in the record. AHP may
deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. If you are
a parent or legal guardian of a minor, please note that certain portions of the minor's medical record will not be accessible
to you. On your request, the AHP Privacy Officer will discuss with you the details of the request and denial process.
E. Right to Request Amendment: You have the right to request an amendment of PHI for as long as the PHI is
maintained in the record. Your request must be in writing, and it must explain why the information should be amended.
AHP may deny your request under certain circumstances.
F. Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for purposes
other than treatment, payment or health care operations, excluding disclosures made to you or disclosures otherwise
authorized by you. On your request, the AHP Privacy Officer will discuss with you the details of the accounting process.
G. Right to Be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a
breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not
been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that
your PHI has been compromised.
H. Right to a Paper Copy: You have the right to obtain a paper copy of the AHP Privacy Notice upon request to your
therapist or the office staff at any time.
I. Questions and Complaints: You may contact the AHP Privacy Officer at Associates in Health Psychology, LLC;
1521 Concord Pike, Suite 103, Wilmington, DE 19803 with questions or complaints. You may also file written
complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. AHP will
not retaliate against you if you file a complaint.
V. Effective Date and Changes to this Notice
A. Effective Date: The original version was effective on April 14, 2003. This Notice was revised February 8, 2010, and
revised again under the “Final Rule” effective September 23, 2013.
B. Changes to this Notice: AHP may change the terms of this Notice and the changes will apply retroactively to all
PHI we maintain. The revised notice will be available upon request, in our office and on our web site.
Forms05\HIPPAtx\AHPPrivNoticeSep13
Associates in Health Psychology, LLC
ACKNOWLEDGMENT OF RECEIPT OF
NOTICE OF PRIVACY POLICIES & PRACTICES
By my signature below I,
, acknowledge that I received a copy of the
Notice of Privacy Policies & Practices for Associates in Health Psychology, LLC.
Signature of client (or personal representative)
Date
If this acknowledgment is signed by a personal representative on behalf of the client, complete the following:
Personal Representative’s Name:
Relationship to Client:
For Office Use Only
I attempted to obtain written acknowledgment of receipt of our Notice of Privacy Policies & Practices, but
acknowledgment could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgment

An emergency situation prevented us from obtaining acknowledgment

Other (Please Specify)
This form will be retained in your medical record.
Forms05\HIPPAtx\AHPPrivNoticeSep13
CONSENT FOR THERAPY/EVALUATION
THE PROCESS OF THERAPY/EVALUATION Psychotherapy is not easily described in general statements.
It varies depending on the personalities of the therapist and client and the particular problems you bring
forward. There are many different methods that therapists at AHP may use to deal with the problems you hope
to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part.
In order for therapy to be most successful, you will have to work on things talked about in our sessions.
Psychotherapy can have benefits and risks. Since therapy sometimes involves discussing unpleasant aspects of
your life, you may at times experience uncomfortable feelings such as sadness, guilt, anger, frustration,
loneliness, and helplessness. At the same time, psychotherapy has been shown to have many positive benefits
for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and
significant reductions in feelings of distress. There are no guarantees of what you will experience, however.
Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal
relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions
about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a
decision that is positive for one family member is viewed quite negatively by another family member.
Sometimes change will be easy and swift, but it can also be slow and even frustrating.
The first one or two meetings will involve a discussion of your concerns and other important aspects of your
life. These meetings allow the therapist to get to know you and to have a context in which to understand your
goals. By the end of the evaluation, your therapist will be able to assess if he/she can be of benefit to you. If so,
your therapist will give you an initial plan of what your work together will include. During the course of
working together, your therapist may ask you for your feedback and views on your therapy, its progress or
about other aspects of the therapy. You are encouraged to respond openly and honestly. It is always
appropriate for you to ask questions about your therapy and your therapist’s view of your progress. All of the
therapists at AHP do their best to create an atmosphere in which you feel safe to disclose your true thoughts and
feelings.
We look forward to working with you to help you successfully face the challenges in your life. Your signature
below indicates that you have read this Consent and understand it.
________________________________________
Client's Signature
_________________________________________
Client's Name (please print)
________________________________________
Parent/Guardian's Signature if client is a minor
_________________________________________
Date
Forms05\Intake\ConsentTherapy&EvalApr14.doc
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
Associates
in Health Psychology, LLC
Newark & Wilmington
__________________________________________________________________________________________________________________________________________________________________________________________________
Parent/Guardian Concerns about Child or Teen (Ages 4-17)
Child’s/Teen’s Name: _____________________________________________
Date of Birth: ______________
Person completing this form: _____________________________________________________
Age: ______
Date: _____________________
For each item on this list, please use the 0-to-3 rating to indicate how much it has concerned you during the past month. Circle the
most appropriate number, using these definitions:
0 = Not at all
1 = A little concern
2 = More than a little
Arguments, “talking back,” smart-alecky
Anxiety, nervousness, often worried, easily frightened
Body image issues
Bullying behavior: picks on, scares, hurts other children, provokes others
Cheating in school
Complaining, whining
Compulsive behaviors or rituals
Computer or electronic games overuse
Constipation
Cruelty to animals
Crying, sadness, feelings are easily hurt
Dawdles, wastes time
Dependence, “clingy” behavior
Difficulties with parent’s new marriage, new partner, or new family
Disobedience, uncooperative, refuses, noncompliant, doesn’t follow rules
Distractibility, inattentive, daydreams, poor concentration, slow to respond
Driving (aggressive, speeding, texting)
Drug or alcohol use
Eating problems – overeating, undereating, appetite issues, poor manners
Failure in school, underachieving
Fears
Fighting, hitting, violent, aggressive, hostile, threatens, destructive
Fire setting
Hair pulling, skin picking
Hypochondriac, often feels sick, complains of aches and pains with no
medical condition
Immature, “clowns around,” has mainly younger playmates
Inferiority feelings, lack of confidence
Interrupts, talks out, yells
Jealousy, feeling jealous
Learning disability or difficulties
Legal difficulties—truancy, vandalism, theft, fighting, drug sales, etc.
Low frustration tolerance, irritability
Lying
Moodiness, mood swings, pouting
3 = A lot of concern
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
0
1
2
3
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
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2
2
2
3
3
3
3
3
3
3
3
3
_______________________________________________________________________________________________________________________________________
(Adapted from The Paper Office)
Forms05/Intake/ParentConcerns Dec13
Associates
in Health Psychology, LLC
Newark & Wilmington
__________________________________________________________________________________________________________________________________________________________________________________________________
Mute, refuses to speak
Need for high degree of supervision at home over play/chores/schedule
Obsessive worries or thoughts
Oppositional, resists, refuses, does not comply, negativism
Overactive, restless, hyperactive, noisy, fidgety
Perfectionism
Pornography
Prejudiced, bigoted, insulting, name calling, intolerant of differences
Procrastination
Recent move, new school, loss of friends
Relationship problems with children/teens (fights, competition,
teasing/provoking)
Rocking or other repetitive movements
Running away from home
School problems–bad grades, hates homework, too much extracurricular
Self-harming behaviors—biting or hitting self, head banging, scratching or
cutting self
Sensory processing sensitivities (such as textures, sounds, etc.)
Sexual—sexual preoccupation, inappropriate sexual behaviors
Sleep problems – too much, too little, insomnia, nightmares, won’t sleep
alone
Social awkwardness
Speech/language difficulties
Suicide talk or attempt
Swearing, blasphemes, bathroom language, foul language
Teased, picked on, victimized, bullied
Temper tantrums, rages
Throwing up
Thumb sucking, finger sucking, hair chewing
Tics—involuntary rapid movements, noises, or word productions
Trauma—experienced or witnessed
Truancy, cuts classes, wants to drop out
Uncoordinated, accident-prone
Underactive, slow-moving or slow-responding, lethargic
Weight, diet, and exercise—too much, too little, conflicts over
Wetting or soiling the bed or clothes
Withdrawal, self-isolation
Other concerns:
Other concerns:
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
0
1
2
3
0
0
0
1
1
1
2
2
2
3
3
3
0
1
2
3
0
0
1
1
2
2
3
3
0
1
2
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
0
1
2
3
0
1
2
3
_______________________________________________________________________________________________________________________________________
(Adapted from The Paper Office)
Forms05/Intake/ParentConcerns Dec13
Associates
in Health Psychology, LLC
Newark & Wilmington
__________________________________________________________________________________________________________________________________________________________________________________________________
Behavioral History for Infants and Toddlers (Ages 0-3 years)
Child’s Name: ___________________________________________________
Date of Birth: ______________
Person completing this form: _____________________________________________________
Age: ______
Date: _____________________
What are some of child’s most likeable qualities? ____________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What time does child:
Get up in the morning? ______________
Take naps? ________________
Go to bed? ______________
What are the family rules you expect or would you like child to follow? ____________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
For each item on this list, please use the 0-to-3 codes to indicate how well it describes child. Circle the most appropriate number, using
these definitions:
0 = Not at all
1 = Just a little
2 = Pretty much
3 = Very much
Fidgets with hands or squirms in seat
0
1
2
3
Enjoys playing with other children
0
1
2
3
Has difficulty remaining seated
0
1
2
3
Is easily distracted
0
1
2
3
Engages in physically dangerous
activities
0
1
2
3
Has difficulty awaiting turn in groups
0
1
2
3
Experienced or witnessed trauma
0
1
2
3
Runs about and is “on the go”
0
1
2
3
Has difficulty when a routine is changed
0
1
2
3
Has difficulty minding or following
instructions
0
1
2
3
Likes to make believe and pretend during
play
0
1
2
3
Has difficulty sustaining attention to tasks
0
1
2
3
0
1
2
3
Shifts from one uncompleted activity to
another
Seems interested in a small part of a toy
or unusual use of a toy
0
1
2
3
Has temper tantrums
0
1
2
3
Becomes clingy or distressed when
separated from caregiver
0
1
2
3
Seems sad or nervous
0
1
2
3
Has little interest in typical play activities
0
1
2
3
Has difficulty maintaining eye contact
0
1
2
3
Interrupts or intrudes on others
0
1
2
3
Repeats some behaviors such as
shaking hands, rocking body, or spinning
0
1
2
3
Does not seem to listen
0
1
2
3
Wiggles fingers or walks on toes
0
1
2
3
Is aggressive (hitting, kicking, etc.)
0
1
2
3
0
1
2
3
Is affectionate
0
1
2
3
0
1
2
3
Follows simple instructions
0
1
2
3
Has difficulty calming down when upset
Has sleep problems – too much, too little,
insomnia, nightmares
Tries to do things on his/her own
0
1
2
3
0
1
2
3
Other concerns:
_______________________________________________________________________________________________________________________________________
Forms05/Intake/InfantToddler Oct12
Associates
in Health Psychology, LLC
Newark & Wilmington
__________________________________________________________________________________________________________________________________________________________________________________________________
Developmental History
Child’s/Teen’s Name: _________________________________________
Date of Birth: ___________________
Person completing this form: ______________________________________________
A. Development
Age: ______
Date: ____________________
Please fill in any information you have about the areas listed below.
1. Pregnancy and delivery
Mother’s prenatal medical conditions and health care, including smoking, prescribed medicines, and street drugs: _____________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Was birth preterm? ______
If so, how many weeks? _____
Weight and length at birth: _____ lbs, _____oz _____ inches
Birth complications, problems, or special treatment: ______________________________________________________________
________________________________________________________________________________________________________
2. The first two years
Breast-fed? ______
If so, for how long? ______________
Allergies: ________________________________________________________________________________________________
Sleep/bedtime patterns or problems: __________________________________________________________________________
________________________________________________________________________________________________________
Diet or feeding/eating challenges: ____________________________________________________________________________
________________________________________________________________________________________________________
Temperament: ___________________________________________________________________________________________
________________________________________________________________________________________________________
3. Milestones: At what age did child do each of these?
Sat without support: __________________________
Stayed dry all night: _________________________________
Didn’t soil his or her pants: _____________________
Walked without holding on: ____________________________
Tied shoelaces: _____________________________
Buttoned buttons: ___________________________________
Helped when being dressed: ___________________
Rode a bicycle without training wheels: __________________
Stayed dry all day: ___________________________
_______________________________________________________________________________________________________________________________________
(Adapted from The Paper Office)
Forms05/Intake/DevelopHistNov13
Developmental
History
Associates in Health Psychology, LLC
__________________________________________________________________________________________________________________________________________________________________________________________________
4. Speech/language development
Age when child said first word understandable to a stranger: ____________
Age when child said first sentence understandable to a stranger: _________
Speech, hearing, or language difficulties or concerns: _____________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
B. Health
1. List all childhood/teenage illnesses, hospitalizations, medications, allergies, head injuries, concussions, important accidents and
injuries, surgeries, periods of loss of consciousness, convulsions/seizures, and other medical conditions.
Condition
2. Current Height: _______________
Age
Treated by whom?
Results
Weight: ________________
Vision or hearing difficulties: ________________________________________________________________________________
________________________________________________________________________________________________________
Sensory sensitivities (such as textures, clothing, sounds, tastes, etc.): ________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
List all past and current medications, vitamins, and supplements: ____________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
(Adapted from The Paper Office)
Forms05/Intake/DevelopHistNov13
2
Developmental
History
Associates in Health Psychology, LLC
__________________________________________________________________________________________________________________________________________________________________________________________________
C. Residences
1. Homes
Dates
From
To
Location
With whom?
Reason for moving
Problems?
2. Residential placements, institutional placements, or foster care
Dates
From
To
Program name or location
Reason for placement
Problems?
D. Schools/Other Education
1. Early intervention services (ages birth through 5 years, either private or through a state agency)
Program (name, location)
2. Schools (name, district, phone) (continues next page)
Age
Grade
How well did child do?
Age
How well did child do?
___________________________________________________________________________________________________________________________________
(Adapted from The Paper Office)
Forms05/Intake/DevelopHistNov13
3
Developmental
History
Associates in Health Psychology, LLC
__________________________________________________________________________________________________________________________________________________________________________________________________
Schools, continued (name, district, phone)
Grade
Age
How well did child do?
3. Additional education supports:
Other supports received for learning and/or behavior at school (such as a tutor/aide, 504 plan, IEP): _______________________
_______________________________________________________________________________________________________
If special education services were provided, what was the school’s classification for these services (such as Learning Disability)?
_______________________________________________________________________________________________________
E. Child’s Hobbies and Special Skills/Talents
List hobbies; sports; recreational, musical, and TV preferences; etc. If a child, include toy preferences. ______________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
F. Changes/Loss/Trauma
Please indicate critical events that have impacted child/teen such as burglaries, home burning, abuse, etc. ___________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
G. Other
What else you would like us to know about this child/teen or family, including religious, ethnic, or cultural background? _________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
For Parents/Guardians of OLDER CHILDREN and TEENS, PLEASE COMPLETE NEXT PAGE
___________________________________________________________________________________________________________________________________
(Adapted from The Paper Office)
Forms05/Intake/DevelopHistNov13
4
Developmental
History
Associates in Health Psychology, LLC
__________________________________________________________________________________________________________________________________________________________________________________________________
H. For OLDER CHILDREN and TEENS
This section helps us to understand overall health issues.
1. Vaccinations: Has teen had Gardasil vaccination? ____________
Has teen had Hepatitis B vaccination? ___________
2. Body art: Does teen have tatoos? ____________
Does teen have body piercings? ________________
3. Sleep: Please describe sleep habits, such as time to bed, time wakes up, naps. _______________________________________
________________________________________________________________________________________________________
4. Mealtime: Please describe mealtime and snack routines, also indicating if you have concerns. ____________________________
________________________________________________________________________________________________________
5. Cigarettes: Does teen smoke cigarettes? ________
If so, please indicate start date and how much. ___________________
________________________________________________________________________________________________________
6. Alcohol: Does teen drink alcohol? ________
If so, please indicate start date and how much. ___________________
________________________________________________________________________________________________________
7. Illicit drugs: Has teen experimented with illicit drugs or currently use any? If so, please complete following:
Drug
Start Date
End Date
How much?
8. Sex related: Has teen ever been sexually active (broadly defined)? __________
Treatment received?
If so, please indicate related information such
as birth control, STDs, contraception and safety measures.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
9. Female only: Age at first period: __________
Please describe how regular period is, problems with heavy bleeding or mood changes, etc. ______________________________
________________________________________________________________________________________________________
5
___________________________________________________________________________________________________________________________________
(Adapted from The Paper Office)
Forms05/Intake/DevelopHistNov13
ASSIGNMENT OF INSURANCE BENEFITS
You must complete and sign this form in order for us to bill your insurance
company. We will also need to copy your insurance card and photo ID at your initial
meeting and any time there are changes to your policy. Please note that your
insurance will not cover missed sessions and you will be responsible for the fee.
It is the policy of Associates in Health Psychology to require 24 hours notice for a
missed session. You may leave a message for your therapist 24 hours a day, 7 days a
week.
I authorize release of all information necessary to process my insurance claims for
services received from Associates in Health Psychology, LLC. I assign all medical
and/or mental health benefits to which I am entitled for these services to Associates in
Health Psychology, LLC. This assignment will remain in effect until revoked by me in
writing. A photocopy of this assignment is to be considered as valid as the original.
I understand that I am responsible for knowing what my insurance policy covers, and
I am financially responsible for paying co-pays, deductibles, and any other balances
not paid by my insurance, such as those listed in the AHP Office Policies. I have read
this information and understand it.
Please print all responses:
Insurance Company covering client:
Insurance ID# for policy covering client:
Name of Policy Holder (if not client):
Policy Holder’s Date of Birth:
Policy Holder’s Social Security Number:
Policy Holder’s Place of Employment:
Policy Holder’s relationship to Client:
Financially Responsible Party (if not Client):
___________________________________
Client’s Name (please print)
_________________
Client’s Date of Birth
___________________________________
Signature of Financially Responsible Party
_________________
Date
Forms05\Intake\InsurAssignmentApr14.doc
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
Health Insurance and Managed Care Release
I have agreed to see you under the terms set by the health insurance/managed care company which oversees your
mental health benefits. Managed care means that an outside company selects approved therapists and determines
both the need for treatment and the length of time treatment will be provided. The following paragraphs outline
some of the general aspects of managed care contracts you should know about.
1) The managed care company may require regular and somewhat detailed reports regarding your symptoms,
diagnosis and treatment. There are no restrictions on the type or amount of information they may require. I will be
glad to discuss the content of these reports with you. Although my experience is that the information provided has
been treated with an appropriate degree of confidentiality, I cannot be responsible in any way for the health
insurance/managed care company's use or re-disclosure of the information provided to them.
2) In some instances, the managed care company must approve all sessions in advance. Each company has its own
criteria regarding what it considers as a "medical need" for therapy, which may differ from your and my assessment
of your need for therapy. I will take responsibility for the timely filing of requests for additional sessions, and I will
notify you of the outcome of these requests. However, provided I have met my responsibilities as stated above, you
will be financially responsible for direct payment of any charges which are not paid by your insurance.
3) At times, the managed care company may provide us with information concerning your previous mental health
history. This may include information on symptoms, diagnosis, and/or treatment. If you have ever had any
treatment that included substance abuse issues, provide the name(s) of the treatment facility and/or provider(s)
and the dates of treatment. Your initials below give me permission to obtain more information about your prior
substance abuse issues and/or related treatment from your managed care company, which in turn will help me to
support you more fully.
Not applicable _____
Prior Treatment Facility & or Provider Name(s) and Address:____________________________________________
______________________________Dates of Treatment:
Client Initials: ____________
Prior Treatment Facility & or Provider Name(s) and Address:____________________________________________
______________________________Dates of Treatment:
Client Initials: ____________
4) As explained in our Office Policies, it is our practice to charge for all canceled sessions if at least 24-hours notice
is not provided. Monday appointments must be canceled by the previous Friday. Please note that you can leave a
message for me 24 hours a day, 7 days a week. Insurance companies will not pay for missed sessions. Therefore,
you will be responsible for the full fee. You are also responsible for any co-payments and deductibles not covered
by your insurance. You may find out what these are by asking your insurance company or I will have information
available by your next appointment.
I will be glad to answer any questions you may have. Please sign this form indicating that you have read this
information and authorize release of information to your managed care company. This release will expire 3 months
beyond the period of time that you are in treatment with a behavioral health therapist at Associates in Health
Psychology, LLC.
_______________________________________________
Client Signature
_____________________
Date
____________________________________
Parent/Guardian Signature if client is a minor
Forms05\Intake\InsManagCare ReleaseApr14.doc
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
CO-PAYS, CO-INSURANCES, and DEDUCTIBLES
Due to policy provisions in your contract with your insurance carrier, we are obligated to collect
your co-pay, co-insurance, and/or deductible. Payment is expected at each visit.
If your insurance policy has provisions such as deductibles, co-insurances, or co-payments, please
note that these provisions have been agreed to between you and your carrier. We cannot legally
discount fees submitted for services submitted for insurance reimbursement.
If our office had verified that your therapist has contracted with your mental health insurance plan,
we have additional contractual obligations to collect the balances as outlined by your insurance
company. Your out-of-pocket maximum will not be calculated correctly if we do not collect what
your insurance company expects us to collect. Furthermore, Associates in Health Psychology’s
contract with your carrier will be jeopardized if we do not collect your co-insurance, co-payment,
and/or deductible.
Additionally, for those Medicare clients who receive services eligible under Medicare, the terms of
the anti-kickback laws obligate us to collect the co-insurance, co-payment, and/or deductible.
We sincerely regret any inconvenience which might be caused by these regulatory or contractual
provisions, but we must be bound by all provisions of insurance policy and federal law. Associates
in Health Psychology will be happy to assist you in resolving any issues or concerns regarding your
insurance.
Please feel free to contact us with any questions you may have.
Forms05\Intake\Co-payDeductibleApr14.doc
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
AUTHORIZATION TO RELEASE INFORMATION: CHILD & ADOLESCENT
The Parent(s)/guardian(s) of__________________________________ Date of birth___________________________
(Minor=s Name)
(Minor=s)
authorize_____________________________________________________________________________________________,
(Name of Provider at AHP)
of Associates in Health Psychology, LLC to release/obtain information in this minor=s medical records,
to/from :__________________________________________Address:_____________________________________________
(Minor s Therapist, Primary Care Physician, or Specialist)
for the purpose of______________________________________________________________________________________
_______________________________________________________________________________________________________.
This information may include diagnoses, treatment information and other notations; substance abuse
information; and information on AIDS/HIV status.
I understand that this information released by this consent is voluntary and it may be revoked by me in
writing at any time. The revocation of this consent will not apply to information released prior to my
revoking this consent. This consent if not withdrawn will be valid for the duration of the related treatment
and billing requirements.
Please note that the released information may not be protected by HIPAA privacy and security rules once it
has been forwarded beyond our facility to the intended recipient. You have the right to refuse this disclosure
to any outside entity listed above or restrict where information may be sent. Please note your restrictions, or
refusal here: ____________________________________________________________________________.
Your therapist has the right to refuse your request for restrictions, but if he/she agrees they are bound by that
agreement.
________________________________________
Parent or Guardian=s Signature
__________________________
Date
_________________________________________
Relationship to Client
_________________________________________
Therapist's Signature
__________________________
Date
Forms05\Release\ReleaseMinorApr14.doc
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
`