New Perspective Counseling Services Child/Teen Intake Form

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1 Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form. The information will help us to better understand your situation as well as potential solutions in helping you get your life back on track. CHILD S INFORMATION Child s Full Name: Nick Name: Date of Birth: Age: Sex: Female Male Grade Level: In an emergency, who do we call? Contact Name: Contact Phone: PARENT/GUARDIAN INFORMATION Mother s Name: Date of Birth: SSN: Street Address: City/State: Zip Code: Home Phone Cell Phone Address: Religious Affiliation (if any): Is it okay to leave a message? Yes No Is it okay to leave a message? Yes No Is it okay to ? Yes No Relationship Status: Single Engaged Married Re-Married Separated Divorced Same-Sex Partners Widowed Father s Name: Date of Birth: SSN: Street Address: City/State: Zip Code: Home Phone Cell Phone Address: Religious Affiliation (if any): Is it okay to leave a message? Yes No Is it okay to leave a message? Yes No Is it okay to ? Yes No Relationship Status: Single Engaged Married Re-Married Separated Divorced Same-Sex Partners Widowed If divorced or not married Parents have: Joint Custody Mother has custody Father has custody Other has custody: Can you provide legal documentation? Yes No INSURANCE INFORMATION: Primary Insurance Carrier: ID #: Group#: Insured: Date of Birth: Employer: Insurance Co. Phone #(Mental Health): Relationship to child: Please be prepared to provide our office staff with your insurance card so that we may make a copy.

2 HOUSEHOLD INFORMATION Pets in the home? Yes No If so, what type? List any other individuals living in your home: Who will participate in your child s therapy? Mom: Yes No Dad: Yes No Sibling: Yes No Step Mom: Yes No Step Dad: Yes No Other: Yes No If yes, who? MEDICAL AND MENTAL HEALTH HISTORY / INFORMATION Primary Physician: Primary Physician Phone: Is the child currently being treated by a physician for any medical conditions? If so, please describe: Is the child currently taking medication? No Yes; Medication name/dose: Has the child ever seen a Psychiatrist or any other mental health provider? No Yes; If yes, when? Focus of treatment: Helpful? Yes No COUNSELING CONCERNS What are the issues for which you are currently seeking assistance? Please be specific (e.g. communication, significant losses, abuse, etc.): What have you previously tried in order to resolve these issues (e.g. religious counseling, talking with family/friends)? Were any of these efforts helpful? Have you noticed anything that tends to make the issues more intensified? What would you say are your child s greatest strengths are as a person? COUNSELING GOALS Goals are very important in counseling. They provide your child s therapist with a focus and direction that will help us to help your child. Please list the goal(s) that you hope to address and achieve in counseling. Please be as specific as possible

3 RISK ASSESSMENT Is there any family history of mental illness or substance abuse? Yes No If so, please list relationship & diagnosis: List any of your child s personal history of emotional, physical, and/or sexual abuse: Has a family member or close friend of your child s ever committed suicide? Yes No If so, please list relationship to your child: Has your child reported having any thoughts of harming self or others? Yes No Self Other(s) Are there any guns or weapons in your house? Yes No If so, please specify what type & who it belongs to: Please list family, friends, support groups and community groups which are helpful to you: Has the child ever been involved in any significant legal actions, currently or in the past (e.g.: lawsuit, probation)? If so, please state under what circumstances: REFERRAL SOURCE How did you learn about this office? (Please check one and provide name as indicated): Insurance Co. Physician Advertising (source) Internet Friend Other By signing below, I confirm that the above information is true and correct. Client s Name (please print): Guardian s Name (please print): Guardian s Signature: Date: / /

4 Client Services Agreement TREATMENT: I understand that I must be committed to attend sessions on a consistent basis in order to receive the greatest benefit from therapy. Although I may stop therapy at any time, I agree to inform my therapist of my decision prior to my last visit. If my therapist believes that I can receive more effective treatment elsewhere, I will be given referrals. I understand that I may not attend a session if I am under the influence of alcohol or drugs, or if I am in possession of a dangerous weapon. My signature below indicates my desire and consent to receive mental health services from New Perspective Counseling Services. PAYMENT & INSURANCE REIMBURSEMENT: I understand that I (the client) am fully responsible for the payment of all fees for services provided regardless of any insurance coverage I may have. I understand that it is NPCS policy that the fee for any session is payable at the beginning of the session. NPCS accepts cash, checks or credit cards as forms of payment. All sessions are minutes in length. The fee for an initial intake session is $ The follow up session fee for individuals, couples or families is $135. While sessions are not conducted by phone, if an emergency phone consultation is initiated by the client, the first 10-minutes are at no charge. However, $25.00 will be billed to your account for each subsequent 15-minute period. This office offers a sliding scale fee based on client income I understand that if I have insurance, NPCS will either file the claim on my behalf or will provide me with the necessary information so that I can file the claim. I understand that I am ultimately responsible for any therapy fee(s) not covered by my insurance carrier. Co-pays and non-covered services are payable at time of service unless other arrangements have been made. In the event that insurance is billed on my (the client) behalf, I authorize payment of mental health benefits to New Perspective Counseling Services. CANCELLATIONS AND MISSED APPOINTMENT AND POLICY I understand that unless a verifiable emergency exists, I must cancel or re-schedule my appointment 24 hours in advance. Sameday cancellations will incur a $50 fee applied to my account and my failure to attend a scheduled appointment without cancellation (a no-show ) will incur a $100 fee to my account. I can expect an invoice to be mailed directly to me if I do not show up or timely cancel a scheduled appointment. The voic system at NPCS records the day and time of all messages left. If I cancel appointments on a consistent basis or miss appointments twice in a row without reasonable cause, NPCS reserves the right to refer me elsewhere for services. I understand that this policy is not meant to be punitive, but instead is to request consideration for the professionals who are providing me a valuable service. My appointment time is reserved for me at the exclusion of others who may be waiting to see the therapist. Since NPCS practice is fee for service, my late cancellation or failure to show for an appointment may result in a loss of income for the therapist. RETURNED CHECKS Any check not honored by your bank for any reason will result in a $25 returned check fee. Returned checks, in some cases, may or may not be processed by the bank twice before deemed insufficient. Returned checks must be paid by cash, money order or credit card. Failure to pay any returned check and fees may result in criminal prosecution. My signature below indicates that I have read, understand, and agree to the statements made above regarding Treatment, Payment & Insurance Reimbursement, and Cancellations and Missed Appointment and Returned Check Policy. Client Name (please print): Guardian Name (please print): Guardian Signature: Date: / /

5 Limits of Confidentiality I understand that the contents of a counseling, intake, or assessment session are protected under the confidentiality laws of the State of Texas. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client s legal guardian. It is the policy of this office not to release any information about a client without a signed release of information. Noted exceptions are as follows: Signed authorization to release information to a specific individual or organization. Therapist determination that you may harm yourself or someone else Disclosure of abuse, neglect, or exploitation of a child, the elderly, or disabled Disclosure of professional misconduct of another mental health professional Court order or requirement by law to disclose information Prenatal exposure to controlled substances In the event of a client s death (the spouse or parents of a deceased client have a right to access their child s or spouse s records) Minors/Guardianship (parents or legal guardians of non-emancipated minor clients have the right to access the client s records) Insurance Companies (only information required for billing purposes) By my signature below, I agree that I understand my right to confidentiality and the above noted exceptions. Client Name (please print): Guardian s Name (please print): Guardian s Signature: Date: / /

6 CAREFULLY. Notice of Privacy Act (HIPAA) 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 The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. "HIPAA" provides penalties for covered entities that misuse personal health information. As required by "HIPAA", we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations. Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. The right to amend your protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of October 1, 2007 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and make the new notice provisions effective for all protected health information that we maintain. You may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. Please contact us for more information at the address found at the bottom of this page. For more information about HIPAA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C Toll Free: (877)

7 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information When we (NPCS and Subcontracted Therapists) consult, evaluate, diagnose, treat, and/or refer you (the client or minor client that you represent), we will be collecting what the law calls protected health information (PHI) about you. We need to use this information in our office to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others to arrange payment for your treatment, to help carry out certain business or government functions, or to help provide other treatment to you. By signing this form, you are also agreeing to let us use your PHI and to send it to others for the purposes described above. Your signature below acknowledges that you have read this notice and are aware our notice of privacy practices, which explains in more detail what your rights are and how we can use and share your information is available to you upon request. If you are concerned about your PHI, you have the right to ask us not to use or share some of it for treatment, payment, or administrative purposes. You will need to submit any limitation requests in writing. Although we will try to respect your wishes, we are not required to accept these limitations. However, if we do accept them, we commit to abide by the limitations that you have requested. After you have signed this consent, you have the right to revoke it by submitting a written request to our Office Manager. Upon receipt of your request, we will discontinue using or sharing your PHI. However, please be advised that we may have already used or shared some of it, and that information cannot be retracted. I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Private Practices. Client Name (please print): Guardian s Name (please print): Guardian s Signature: Date: / /

8 Court Testimony T Agreement & Information I It is in your best interest to know that the therapists at New Perspective Counseling Services (NPCS) are not considered Forensic Psychologists and conducting witness/testimonial services is not in the therapist s area of interest or expertise. If you have a suspicion that your case will be going to court or you need therapist testimony, please let your therapist know and they will provide you with an appropriate referral source that can better meet your needs. If you require services for court, we recommend that you hire another mental health professional for this purpose. Should you subpoena any of the therapists at NPCS as a factual case witness or involve them in court related processes, you agree to pay a retainer fee of $2, that is due at the time a subpoena is served with an additional $ for every hour of the therapist s time involved, including but not limited to phone consultation with client and/or client s attorney about court hearing, drive time, wait time, court testimony and/or deposition, paperwork preparation and any other legal matters. Fees incurred for these services will be charged using credit card on file if other arrangements have not been made prior to court date. NPCS will not release records to any outside party unless so authorized to do so, in writing, by every member of the couple or family in treatment able to execute a waiver unless subpoenaed by the court. If you choose to have a therapist or NPCS employee subpoenaed with or without approval the above charges will apply. Please note that your subpoena may be turned over to an attorney, unless the therapist feels prudent to disclose certain confidential information on the stand that could protect a child, elder, or handicapped person. Initial one of the following: I AM seeking counseling for court testimony or court involvement on behalf of my therapist at NPCS. I AM NOT seeking counseling for court testimony or court involvement on behalf of my therapist at NPCS. By signing this form, you are acknowledging you have let a NPCS representative and/or Therapist (before a counseling relationship is established) know if you and/or your child is attending counseling for court or court related purposes/motivations. By your signature below, you are indicating that you have read and understand this document and any questions you had about this document were answered to your satisfaction. You agree to waive your therapist s involvement in any legal matters they deem not appropriate for their participation. Client Name (please print): Client Signature: Date: / / Therapist Signature: Date: / /

9 Credit Card Authorization Form All appointments must be cancelled 24 hours in advance. Same-day cancellations (a late cancel ) will incur a $50 fee and failure to attend a scheduled appointment without cancellation (a no-show ) will incur a $100 fee that will be automatically charged to your credit card listed below.* This policy is not meant to be punitive, but appointment times you schedule are reserved for you at the exclusion of others who may be waiting to see the therapist. Checks that are written to NPCS or to an NPCS Therapist not honored by your bank for any reason will result in a $25 returned check fee. The credit card below will be charged in the amount of the bounced check and the $25 returned check fee. Outstanding balances on your account due to co-insurance, deductible, or for any non-covered services (e.g., marital/family counseling, telephone consultations, etc.) for more than 30 days will also be charged to the card listed below. (Payment arrangements are available on outstanding balances by contacting the NPCS Office Manager) ***All information must be provided*** Client Name: Therapist Name: Credit Card Type (check one): Visa Master Card American Express Discover Card Number: Expiration Date (mm/yy): CVC Code: Cardholder Name (as it appears on the card): Billing Address for the Credit Card: City, State, Zip: By signing below I certify that my above information is true, accurate and an authorized user on the account. I authorize and agree to have my above credit card information kept on file and charged for Late Cancel appointments, No Show appointments, and outstanding balances on my account that have not been paid or payment arrangements made after 30 days. Cardholder Signature: Date: *the voic system at NPCS records the day and time of all messages left. PLEASE NOTE THAT THIS FORM WILL NOT BE KEPT IN YOUR CLIENT FILE AND THE THERAPIST WILL NOT HAVE ACCESS TO THIS INFORMATION. INSTEAD THIS WILL BE IN A LOCKED FILE IN OUR BILLING OFFICE. THIS FORM IS NOT MEANT TO BE USED FOR PAYMENT AT TIME OF YOUR VISITS. I do do not want a copy of this release

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