NEW PATIENT REGISTRATION

Transcription

1 NEW PATIENT REGISTRATION PARK TUDOR It is required that ALL minors be accompanied by a parent or legal guardian at the initial visit. PATIENT NAME LAST: FIRST: MI: NICKNAME: DATE OF BIRTH: / / AGE: SSN: SEX: MALE / FEMALE ADDRESS: STREET ADDRESS: APT NUMBER: CITY: STATE: ZIP: *Primary Telephone: Secondary Telephone: Primary number will be the first number we utilize to contact you. You will receive a courtesy appointment reminder call at your primary number unless you notify our staff otherwise. PERSON TO CONTACT IN CASE OF EMERGENCY NAME: RELATIONSHIP: HOME PHONE: ( ) CELL PHONE: ( ) PARENT / GUARDIAN INFORMATION Are the child s biological parents currently married? YES NO If no, custody is with Mother primary Father primary Joint Other Are there any legal custody restrictions that we should be aware of? Please describe:

2 FATHERS NAME: DATE OF BIRTH: SSN: OR DRIVERS LICENSE NUMBER: ADDRESS: HOME PHONE: CELL PHONE: EMPLOYER: WORK PHONE: MOTHERS NAME: DATE OF BIRTH: SSN: OR DRIVERS LICENSE NUMBER: ADDRESS: HOME PHONE: CELL PHONE: EMPLOYER: WORK PHONE: LEGAL GUARDIAN (if applicable) SSN: OR DRIVERS LICENSE NUMBER: ADDRESS: HOME PHONE: CELL PHONE: EMPLOYER: WORK PHONE: PRIVATE PAY SERVICES By my signature below: I understand that the services rendered by the service providers of Indiana Health Group for the Park Tudor Application process are not covered by my insurance carrier. Therefore, I will be responsible for all charges incurred with Indiana Health Group. I AGREE AND CONSENT TO PARTICIPATE IN THE SERVICES offered and provided by Indiana Health Group, Inc., and all affiliate providers of Indiana Health Group. I CONSENT TO RECEIVE TELEPHONE CALLS (live and pre recorded), TEXT, or S for purposes including but not limited to scheduling, appointment reminders, billing and account collections and general office notifications. [ ] By checking this box I am declining this service. Signature of Patient/Personal Representative: Date:

3 GENERAL PSYCHIATRIC HISTORY Please list any medications your child currently takes for emotional or behavior problems: [ ] NONE Please list any medications your child has taken in the past for emotional/behavior problems: [ ] NONE Please list any family history of mental health/developmental problems: GENERAL MEDICAL HISTORY Please list all allergies, childhood illnesses (including chronic illnesses and infectious diseases), accidents, injuries, hospitalizations, and surgeries: EDUCATIONAL HISTORY Has your child attended any formal daycare or school? Daycare/School: Grade, if applicable: How many different schools/daycares has your child attended? Has she/he ever repeated or skipped a grade? YES / NO Which one? What is her/his attendance like or how many days per week did he/she attend? Has she/he had any discipline problems at chool/daycare?

4 DEVELOPMENTAL HISTORY Pregnancy Was the pregnancy planned? [ ] YES [ ] NO Please check any of the following experienced during mother s pregnancy with the child being evaluated. [ ] Excessive vomiting [ ] Smoking [ ] Drug use [ ] Excessive spotting/blood loss [ ] Alcohol consumption [ ] Illness [ ] Threatened miscarriage [ ] Prescription medications [ ] X-rays [ ] Toxemia/Infection [ ] Hospitalization (other than delivery) Were there any problems with the pregnancy? Was Pregnancy: [ ] Full Term [ ] Premature how much? [ ] Late how much? Were there any problems with the delivery? Early Childhood Milestones ~ Please report ages or if you cannot remember check on of the following: Smiled [ ] Early [ ] Average [ ] Late Crawled [ ] Early [ ] Average [ ] Late Sat up on own [ ] Early [ ] Average [ ] Late Stood unassisted [ ] Early [ ] Average [ ] Late Walked unassisted [ ] Early [ ] Average [ ] Late Spoke first words [ ] Early [ ] Average [ ] Late Said sentences [ ] Early [ ] Average [ ] Late Toilet Trained [ ] Early [ ] Average [ ] Late Ran [ ] Early [ ] Average [ ] Late Fed Self [ ] Early [ ] Average [ ] Late Dressed Self [ ] Early [ ] Average [ ] Late Have there been any illnesses, behavioral difficulties, or discipline problems during early childhood? Does your child have temper tantrums? [ ] YES [ ] NO Describe: Has your child received any developmental services (i.e. First Steps)?

5 SOCIAL HISTORY Who lives in the home with your child? Are there any stressors within the family at this time or in the past year (financial, marital, housing, etc.)? If Yes, please explain Please briefly describe your child's daily routine (i.e. wake time, daily schedule, meal time, bed time) Does your child easily separate from you and/or his/her other caregivers? [ ] YES [ ] NO Does your child handle transitions, such as from free time to meal time, without significant distress/tantrums? [ ] YES [ ] NO Does your child make friends easily? [ ] YES [ ] NO Does your child have difficulty keeping friends? [ ] YES [ ] NO Does your child avoid making eye contact? [ ] YES [ ] NO Briefly describe any peer interaction problems experienced by your child: Please describe any losses, changes, or transitions in your child s life? Please describe your child s strengths, weaknesses, accomplishments, talents, and areas of interest:

6 CHILD PROBLEM CHECKLIST Below are some common problems of children. Please read each item carefully. If an item applies to the child please mark appropriately. Any comment will be especially helpful. BEHAVIOR PROBLEMS [ ] Violates Curfew [ ] Destroys Property [ ] Steals [ ] Lies often [ ] Has been in trouble with police/probation [ ] Has runaway from home [ ] Has attempted or talked about suicide [ ] Argues when told to do something [ ] Is cruel to animals [ ] Rarely sits still [ ] Has to have everything his/her own way [ ] Acts like a younger child [ ] Has problems with anger [ ] Sets fire [ ] Prefers to be alone ACADEMIC PROBLEMS [ ] Is truant from school [ ] Does not complete assignments in the classroom [ ] Does not do homework [ ] Is in special education classes [ ] Feels unfairly treated by teachers/administrators [ ] Has a short attention span [ ] Often clowns in class [ ] Cheats [ ] Is too often out of seat at school [ ] Misses school for a variety of reasons [ ] Makes below average grades PROBLEMS WITH FEELINGS [ ] Is upset by any changes in routines/schedules [ ] Has a lot of fears [ ] Lacks self confidence [ ] Feels sad a lot [ ] Does not seem to feel guilt [ ] Is extremely critical [ ] Cries easily or often [ ] Does not like to be touched [ ] Resents even gentle criticism [ ] Has an I don t care attitude [ ] Feels bored a lot [ ] Has frequent nightmares PROBLEMS WITH THINKING [ ] Says and does things over and over [ ] Hears or sees things that aren t there [ ] Has trouble concentrating [ ] Has ideas that don t make sense FAMILY PROBLEMS [ ] Avoids contact with family members [ ] Gets along poorly with mother [ ] Gets along poorly with father [ ] Gets along poorly with siblings [ ] Parents get along poorly with each other [ ] Clings to mother [ ] Clings to father SOCIAL PROBLEMS [ ] Hangs around with a bad crowd [ ] Is too easily led by others [ ] Chooses friends a lot younger [ ] Chooses friends a lot older [ ] Teases younger children [ ] Doesn t like being alone [ ] Has few friends [ ] Tattles on other children [ ] Seems shy [ ] Often boasts [ ] Often interrupts others [ ] Won t argue/fight back when most would [ ] Fights DRUG/ALCOHOL ABUSE [ ] Uses alcoholic beverages [ ] Uses drugs [ ] Sells drugs [ ] Smokes cigarettes PHYSICAL COMPLAINTS [ ] Has a lot of physical complaints [ ] Has trouble sleeping [ ] Sleeps a lot [ ] Is seriously overweight [ ] Is seriously underweight [ ] Has lost a lot of weight recently [ ] Has gained a lot of weight recently [ ] Has poor bladder control at night [ ] Has poor bladder control during the day [ ] Has poor bowel control at night [ ] Has poor bowel control during the day [ ] Is clumsy or awkwar

7 Authorization to Release Protected Health Information to Professional Individuals or Facilities 1) Indiana Health Group is to: send records to the following: request records from the following: scan/keep on file for communication 2) Name of Individual / Facility: Park Tudor School 7200 N. College Avenue Indianapolis, IN Phone: (317) Fax: (317) ) Release Records for the following dates of service: ALL OR ONLY for dates specified From: To 4) Information Requested (please check all that apply): Entire Patient Record Treatment Notes Diagnosis Medications Discharge Summary Substance Abuse Evaluation Testing Results Billing Statements School Records Other: Assessment and Reports 5) Purpose of Release: Treatment / Continued Care Verbal Communication Other: Admissions Assessment 6) This request will be valid for one year from the date signed unless I indicate an earlier date or event here We will process your request as quickly as possible however PLEASE ALLOW UP TO 30 DAYS Charges will be applied according to Indiana state statute. A $10.00 rush fee will be applied if records are requested to be sent within 2 business days. By my signature below I understand: This authorization may be revoked at any time by sending written notification to Indiana Health Group. This release prohibits redisclosure except in accordance with 42 C.F.R., 21 et seq., which is a federal regulation governing release and use of patient record information pertaining to treatment for alcohol and drug abuse. Indiana Health Group will not condition my treatment whether I provide authorization for the requested use or disclosure. A copy of this authorization shall be as valid as the original. I understand that: I have the right to inspect or copy the protected health information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights). I have the right to refuse to sign this authorization. I have the right to receive a signed copy of this authorization. Indiana Health Group reserves the right to charge for the reproduction of Medical Records in accordance with state law code 760 IAC Unless listed above, I understand that this release also pertains to records whose confidentiality is protected by either Federal Regulations (42 CFR Part 2) or State Law (IC ) concerning hospitalization or treatment, including but not limited to, information regarding treatment and related services for alcohol and/or substance abuse, communicable disease documentation, human immunodeficiency virus (HIV) or for mental health treatment or counseling. THIS IS A LEGAL DOCUMENT. Please read and complete carefully. By your signature below you agree that you understand & agree to the terms. If the patient is 18 years of age or older, the patient must sign and date the form. If the patient is 18 years of age or older and is incapable of signing, a legally authorized representative may sign and date the form. Please indicate your legal authority and include documentation: Legal Guardian Health Care Agent (Health Care Power of Attorney) If the patient is 17 years of age or younger, the patient s parent or legal guardian must sign and date the form, unless an exception exists under state or federal law. Please indicate your relationship: Parent Legal Guardian Signature (Required) Date Signed (Required) Printed Name of Person Signing this ROI: Patient Mailing Address: Patient Telephone: Patient INDIANA HEALTH GROUP USE ONLY Received and Reviewed By: DATE: Release was Processed By: DATE: Description of Processing: