CONFIDENTIAL PATIENT INFORMATION FOR MINOR CHILD Child's Name
MM slash DD slash YYYY
Parent Information Parent Name *
Are you the custodial parent? If not, name of custodial parent Date of Birth *
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Social Security Number * Cell Phone Home Phone Work Phone Address
* Marital Status * Occuption Place of Employment May we contact you at work? May we leave messages for you at work? Spouse's Name
Spouse's Education/ Occupation Referred by Patient Information Patient's Name
Patient Date of Birth *
MM slash DD slash YYYY
Patient SSN * Patient Address
* Gender Grade Name of school Teacher's name Is your child currently under a doctor's care for any medical problems?? If yes, please describe. Has your child had any previous psychological treatment or evaluation? If yes, please describe. Please check any of the following concerns that apply to your child: What is your primary concern regarding your child/reason for visit? What have others told you about your child's behavior/ problems (doctors, teachers, etc.)? What would you like to happen as a result of seeking services? What have you told/ plan to tell your child about coming to this office? What are his/her feelings about coming? Please list a few of your child's strengths/ assets Developmental milestones
At what age did your child master the following milestones? Please use the drop-down menus to answer.
Smile 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Sit without support 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Roll over 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Crawl 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Pull to stand 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Walk alone 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Walk up stairs 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Hold a cup 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Speak first word 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Speak short phrases 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Speak in sentences 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Fully bladder trained 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Fully bowel trained 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Stay dry all night 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Hold a pencil correctly 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Pedal a bicycle 0-3 months 3-6 months 7-12 months 13-18 months 19-24 months 2-3 years 3-4 years Other Family Information
Caregivers: Biological parents, step-parents, and any other significant adult providing care for the child
Marital status of parents Date divorced/ separated, if applicable Are both parents living? Parental date(s) of death, if applicable Please indicate any recent family stressors Persons living in the home Family interactions: How well does the family get along? What are typical activities? Family Medical History
Please indicate below if any of the child's relatives (parent, brother, sister, aunt, cousin, etc.) have been treated for the following:
For each item checked above, please specify relationship of treated individual to child Siblings
Include all mother's pregnancies. Begin with the first and include miscarriages/ stillbirths.
Father's children by other unions.
List all physicians and therapists your child has previously seen or is currently seeing.
INFORMED CONSENT TO TREAT
I understand there are risks, varying lengths and methods of treatment, as well as possible consequences of the decided treatment which typically includes, some, or many of the following methods and interventions: Stabilization, Decrease and relieve symptomatology, Improve coping, Skill development, Grief resolution, Stress management, Behavior modification, Medication management
1. While I expect benefits from this treatment I fully understand and accept that because of factors beyond ourcontrol, such benefits and desired outcomes cannot be guaranteed.
2. I understand that this mental health provider does not provide emergency service and I will be informed of whom/where to call in an emergency or during the evening or weekend hours.
3. I understand that regular attendance will produce the maximum possible benefits but that I am free to discontinue treatment at any time in accordance with office policies.
4. I understand that I am financially responsible for any portion of the fees not covered or reimbursed by my health insurance.
5. I have been informed and understand the limits of confidentiality, that by law, the therapist must report to appropriate authorities any suspected child abuse or serious threat of harm to myself or another person.
6. I am not aware of any reason why I should not proceed with therapy/treatment and I agree to participate fully and voluntarily.
7. If applicable, I am the custodial parent of a minor child. I hereby give the non-custodial parent, permission to seek treatment on our child’s behalf. The provider practices with an association of independently practicing professionals which share certain expenses and administrative functions under the name PCA Resources, Inc. While they share office space, this provider is a completely independent professional rendering clinical services and is fully responsible for those services. Clinical records are separately maintained and other professionals cannot have access to them without your specific written permission. If you have any questions regarding this policy, please discuss these with the provider as soon as possible. Your signature below indicates consent for psychological/psychiatric treatment and indicates that you have read the above statement and agree to the above terms. Your commitment to this process and your assistance in understanding these necessary policies are an important part of your care.
Consent * LIMITS OF PATIENT CONFIDENTIALITY
Mental Health Providers have a legal obligation or duty to maintain the confidentiality of their communications with their patients. There are exceptions, however, to this right of confidentiality. These include the following: *You are a danger to yourself or others. *Child abuse is disclosed.*Elder abuse is disclosed.*You seek treatment to avoid detection or apprehension or enable anyone to commit a crime. *Your therapist was appointed by the courts to evaluate you. *Your contact with your therapist is for the purpose of determining sanity in a criminal proceeding. *Your contact is for the purpose of establishing your competence. *Your contact is one in which your therapist must file a report to a public employer or as to information required to be recorded in a public office, if such report or record is open to public inspection.*You are under the age of 16 years and are the victim of a crime.*You are a minor and your therapist reasonably suspects you are the victim of child abuse. *You are a person over the age of 65 and your therapist believes you are the victim of physical abuse. *If you are deceased and the communication is important to decide an issue concerning a deed or conveyance, will or other writing executed by you affecting interest in property. *You file suit against your therapist for breach of duty or your therapist files suit against you. *You have filed suit against anyone and have claimed mental/emotional damages as part of the suit. *You waive your rights to privilege or give consent to limited disclosure by your therapist.*Your insurance company paying for services has the right to review all records. If you have any questions about these limitations, please discuss them with your therapist. I am consenting to receiving outpatient mental health treatment and understand my legal right to confidence and the aforementioned exceptions.