Kids Therapy and Testing

Kids Form

Step 1 of 3

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Provider Name:(Required)

Please select the provider that you are scheduled to see.

Child's Name(Required)

First Last

Date

MM slash DD slash YYYY

Parent Information

Parent Name(Required)

First Last

Are you the custodial parent?

Yes

If not, name of custodial parent

Date of Birth(Required)

Month

Day

Year

Social Security Number

Cell Phone

Home Phone

Work Phone

Address(Required)

Street Address Address Line 2 City State ZIP Code

Marital Status(Required)

Single

Married

Widowed

Divorced

Other - Please Specify

Occuption

Place of Employment

May we contact you at work?

Yes

May we leave messages for you at work?

Yes

Spouse's Name

First Last

Spouse's Education/ Occupation

Referred by

Patient Information

Patient's Name

First Last

Patient Date of Birth(Required)

MM slash DD slash YYYY

Patient SSN

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Gender

Male

Female

Other - Please Specify

Grade

Name of school

Teacher's name

Is your child currently under a doctor's care for any medical problems??

Yes

If yes, please describe.

Has your child had any previous psychological treatment or evaluation?

Yes

If yes, please describe.

Please check any of the following concerns that apply to your child:

Sleep problems

Eating problems

Energy level

Memory

Sadness

Irritability

Increased talking

Defiance to authority

Racing heart/ Difficulty breathing

Fears of dying or going crazy

Excessive shyness

Poor social skills

Toileting concerns

Self-injury

Loss of enjoyment of activities

Alcohol/ substance abuse

Guilt

Elation

Academic problems

Aggression

Hopelessness

Poor judgement

Compulsive behavior

Temper tantrums

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

Sit without support

Roll over

Crawl

Pull to stand

Walk alone

Walk up stairs

Hold a cup

Speak first word

Speak short phrases

Speak in sentences

Fully bladder trained

Fully bowel trained

Stay dry all night

Hold a pencil correctly

Pedal a bicycle

Family Information

Caregivers: Biological parents, step-parents, and any other significant adult providing care for the child

Family Information

Name

Relationship to child

Occupation

Highest grade completed

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:

Convulsions/ seizures

Cerebral palsy

Muscle weakness

Muscle tics/ twitches

Tourette's Syndrome

Headache/ migraine

Tuberculosis

Hepatitis

HIV/ AIDS

Skin disease

Kidney disease

Bone disease

Stroke

Cancer

Learning problems

Attention problems

Speech problems

Vision problems

Hearing loss

Intellectual Disability

Hyperactivity

Emotional problems

Legal trouble/ jail

Drug addiction

Alcoholism

Violence

Mental illness

Nervous breakdown

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.

Year

Father's last name

Length of labor

Problems at birth

Any physical, emotional, behavioral, or educational problems?

Siblings

Father's children by other unions.

Year

Father's last name

Length of labor

Problems at birth

Any physical, emotional, behavioral, or educational problems?

Treatment History

List all physicians and therapists your child has previously seen or is currently seeing.

Name

City

Reason for visit

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(Required)

I agree

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.

Consent(Required)

I agree

AUTHORIZATION TO CONTACT

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICE

By signing above, I acknowledge that I have received a copy of the Notice of Privacy Practices. The notice describes how my health information may be used or disclosed. I understand that I should read it carefully. I am aware that the notice may be changed at any time and that I may obtain a revised copy of the notice at the clinic location where I receive healthcare services.

RELEASE OF INFORMATION FOR REFERRING PROVIDER

I authorize the provider to contact, or confirm with the referring provider an appointment made for follow-up as well as general information pertaining to psychological and emotional function if indicated. I understand detailed clinical information will not be released without my written consent.

EMAIL AUTHORIZATION

By providing my email address above, I hereby agree to allow the provider to contact me by email regarding my child. I understand that my email will not be shared with any outside companies.

RELEASE OF SCHOOL EXCUSE

I authorize the provider to send a school excuse to my child’s school.

Name of school

School phone

SPOUSE INFORMATION or CUSTODIAL PARENT/GUARDIAN INFORMATION (if the patient is a minor)

Name

First Last

Date of Birth

MM slash DD slash YYYY

SSN

Relationship

Phone

Emergency Contact

Name

First Last

Relationship

Phone

PATIENT REPSONSIBILITY

I understand that I have contracted for services with the provider and that I alone am responsible for paying the amount that is billed for services. In particular, 1.I understand that PCA Resources, Inc. provides insurance filing as a courtesy and a convenience to me and/or will seek authorizations from my health care provider; however, these activities do not guarantee that my insurer will pay. I understand that at any time I am free to file my own insurance, in which case full payment of fees will be required at the time of service.2.I understand that the business office will attempt to help me understand my insurance or managed care benefits and procedures, but that denial of benefits by my insurer means that I am fully responsible for the contracted amount. 3.I understand that I am responsible for meeting the requirements of my health insurer or managed care provider. In particular, I am responsible for: Obtaining the initial referral to the provider, if needed. Ensuring I have pre-certification of visits, if needed. Knowing limits regarding my deductible. Keeping track of benefit limits. Keeping track of my benefits entails knowing any limits on my policy and ensuring that I do not exceed those limits (e.g., some insurers set a maximum of 20 mental health sessions per year). If I exceed my limits and my insurer refuses to pay, I will be responsible for the amount refused. Also, I understand that if I am seeing another social worker, psychologist or psychiatrist, those sessions may count against my mental health benefits. I also realize that while my managed care provider may authorize visits as appropriate for me, that does not mean that they will necessarily pay for those visits (e.g., Some insurers will authorize 35 visits when they will only pay for 30 visits). 4.A fee of $150.00 per scheduled hour will be charged if I do not give a 24 hour notice (during normal business hours) to cancel an appointment, with the exception of mutually agreed upon emergencies. Insurance cannot be billed for this fee, as they will not pay for missed appointments. 5.A fee of $37.50 will be charged to my account for every 15 minutes I am late for a scheduled appointment. In addition, any other work, such as phone calls, letter writing, case management, etc. that take more than 15 minutes will be billed in 15 minute increments at $37.50 each. Insurance cannot be billed for either of these fees. 6.I understand that if my policy changes or if I switch insurance companies, I should inform the office immediately. If the office does not have the proper information and cannot collect payment from the insurer, I am responsible for the amount the insurance company will not pay. 7.I also understand that in the instance of my account getting turned over to collections that I am responsible for the entire bill plus 100% of collection fees.

Consent(Required)

I agree

PATIENT RESPONSIBILITY FOR LITIGATION

I understand that I have contracted for psychiatric services with the provider and that I alone am responsible for paying the amount that is billed for services. In particular, 1.Due to complexity and difficulty of legal involvement, the provider charges $300.00 per hour for preparation and attendance at any legal proceedings.2.Court appearances are charged in 4 hour increments (e.g. 8:00 am to 12:00 pm or 1:00 pm to 5:00 pm, at $1,200.00 per half day). These charges apply regardless of whether testimony is given. 3.Payment will be required in full by 5:00 pm 3 business days prior to the scheduled court proceedings. In the event that the case is settled or less time is required, the excess amount paid will be promptly refunded. 4.We cannot bill your insurance company for any charges related to litigation.5.If a third party, such as your attorney, is responsible for the fees incurred it is your responsibility to ensure payment. If the third party, even if contractually obligated to pay, does not pay, I will be responsible for the full balance plus any additional fees incurred if the account is referred to an attorney for collection. a.If a third party is responsible for payment, the obligations must be in writing, signed, and preserved.b.Payment will be required in full by 5:00 pm 3 business days prior to the scheduled court proceedings. 6.Court ordered evaluations are only accepted with advanced retainer of $5,000.00 plus, for psychologists, advance payment for the cost of the evaluation ($300.00 per face-to-face hour at approximately 12-14 hours total).

Consent(Required)

I agree

PRIMARY INSURANCE INFORMATION

Patient’s relationship to Policy Holder:

Self

Spouse

Child

Stepchild

Other - Please Specify

Insurance Company:

Insurance Company Phone

Policy Holder’s Name

First Last

Policy Holder’s SSN

Policy Holder’s Phone

Policy Holder’s Date of Birth

MM slash DD slash YYYY

Policy Holder’s Address

Street Address Address Line 2 City State ZIP Code

ID / Policy#

Group/Plan/Division #

Employer

SECONDARY INSURANCE INFORMATION

Patient’s relationship to Policy Holder:

Self

Spouse

Child

Stepchild

Other - Please Specify

Insurance Company:

Insurance Company Phone

Policy Holder’s Name

First Last

The policy holder is the primary person on the policy. For example, an employer based plan would be the person that works for that employer.

Policy Holder’s SSN

Policy Holder’s Phone

Policy Holder’s Date of Birth

MM slash DD slash YYYY

Policy Holder’s Address

Street Address Address Line 2 City State ZIP Code

ID / Policy#

Untitled

Group/Plan/Division #

Employer

AUTHORIZATION FOR INSURANCE PAYMENT

My signature above indicates that I agree to authorize payment of insurance benefits to the service provider, authorize the release of any information necessary to process insurance claims, and accept payment responsibility of the portion of the bill which insurance does not cover

PERSON RESPONSIBLE FOR PAYMENT

Patient

Parent listed above

Other (complete the fields below)

Name

First Last

Relationship

Date of Birth

MM slash DD slash YYYY

SSN

Phone

RELEASE TO DISCUSS FINANCIAL INFORMATION

Name

Address

Phone

Relationship

We cannot share information about your financial account with anyone unless we have your written authorization. The exceptions to this are biological parents of a minor child, those listed as legal guardians of adults, or anyone listed here. I hereby authorize the provider and/or staff to disclose financial information with the listed person(s).