Child Intake Form - Rock Landing Psychological Group

Name of child

Age

Name your child prefers to go by

Date Of Birth

Sex

Female

Male

Ethnicity

Address

City, State, ZIP

Your Relationship to Client

Parent

Guardian

Name

Date Of Birth

Address, city, state

Sex

Female

Male

Social Security Number

Employer

Occupation

Preferred Contact Number

THE OTHER PARENT IS:

Name

Phone

INSURANCE INFORMATION

Primary Insurance

Subscriber Date of Birth

Subscriber Name

Subscriber SSN

Policy ID #

Group #

Subscriber’s Employer

Work Phone

Secondary Insurance

Subscriber Date Of Birth

Subscriber Name

Subscriber SSN

Policy ID #

Group #

Subscriber’s Employer

Work Phone

Treatment Contract

Insurance and Financial Policy Statement

Thank you for choosing Rock Landing Psychological Group for counseling. As part of providing high quality services, we need to clarify our financial policies. Should you have any questions regarding the practice policies, please ask a member of the staff for clarification.

If you are using your health insurance benefits, we will bill your insurance company. To do so, we need you to provide us with accurate and timely information regarding your insurance. All co-pays, deductibles, and denied payments are your responsibility. Your health insurance company may require you to make a co-payment and/or satisfy a deductible. The co-payment is determined by your health insurance company and is due at the time of service. If you have a deductible which has not been met, then the full fee is due until the deductible has been met.

I authorized a release of information to my health insurance company and I assign all benefits to Rock Landing Psychological Group.

Late Cancellation/No Show Fee

Rock Landing Psychological Group requires 24 hour notice for routine cancellations. Late cancellations and no shows will incur a $65.00 charge for a missed appointment with your therapist and a $75.00 charge for missed appointment with your psychiatrist to be paid at your next scheduled session. Please note that your health insurance company will not cover this fee. The practice has a 24 hour voice mail system to take your cancellations. Please call (757) 873-1736 and speak to a staff member or if it is after hours leave a message for he scheduling staff on the voice mail system. At the time of check out you are given a card with the date of your next scheduled appointment. Our office will make every effort to remind you of your scheduled appointment. However, it is your responsibility to be aware of your appointment. Repeated cancellations and/or missed appointments may result in being disengaged from this practice.

Late Cancellation/No Show Fee for Psychological Testing

The psychologist requires 72 hours for cancellation for testing. Late cancellations and no shows will incur a $65.00 charge for each hour the individual was scheduled for testing. Please note the health insurance company will not cover this fee. Please be aware it will be at the discretion of the examiner as to whether or not the individual will be rescheduled for testing.

Parent/Guardian Signature

Clear

Date

Consent to Treatment

I do hereby seek and consent to take part in the treatment of my child provided by Rock Landing Psychological Group.

I understand that developing a treatment plan for my child with the provider(s) of care, and regularly reviewing the work towards meeting the treatment goals are in my child’s best interest. I agree to play an active role in this process.

I am aware that no promises have been made to me regarding the outcome of treatment rendered by my child’s provider(s) of care.

Parent/Guardian Signature

Clear

Date

Coordination of Treatment

If my child is referred to any other clinician or physician at Rock Landing Psychological Group, I give my consent for those clinicians to obtain and release pertinent information to each other for the purpose of coordinating the care of my child.

Parent/Guardian Signature

Clear

Date

Agreement

I hereby attest that all information contained in these pages is current and correct. I understand that I am responsible for informing Rock Landing Psychological Group of any changes. Failure to do so may delay processing of insurance claims, in which case I will incur responsibility for those unpaid claims. Falsification of this information is punishable under Federal Law. I have received a copy of the Notice of Privacy Information Practices (HIPAA) pertaining to this practice.

Parent/Guardian Signature

Clear

Date

Permission to Call

We may need to reach you to verify or discuss an appointment. Please indicate below how you would prefer us to contact you.

Do you give permission to call my home and/or leave a message there?

I Give Permission

I Do Not Give Permission

Do you give permission to call my place of employment and/or leave a message there?

I Give Permission

I Do Not Give Permission

I give my permission for this person to Coordinate my appointments for my child

I DO NOT give my permission for this person to Coordinate my appointments for my child

Referral Information

Who referred you to this practice?

May we have permission to thank them for your referral?

Yes

Has your child been seen here before?

Yes

If yes please give approximate date and reason for seeking counseling

Legal Information

Are you and/or your child currently involved in the legal system?

Check all which apply.

Child Custody

DUI/DWI

Disability

Lawsuit

Other

Others In The Home

Parent/Guardian Signature

Clear

Date

Brief Health Information

Prescription medications your child takes.

List medication, dosage, and what it's taken for

Has your child experienced any diseases, illnesses, significant accidents, injuries, hospitalizations, surgeries, periods of loss of consciousness, other medical conditions?

Please list age, illness, treatment, treated by and the result of the treatment.

Is your child now being treated for any medical condition?

Yes

If “yes” name or describe condition

Your child’s health is:

Excellent

Good

Fair

Poor

Does your child have any allergies?

Yes

If yes, please list below by allergy, reaction and medications taken.

Health Habits

Does your child smoke cigarettes or use tobacco products?

Yes

Don't know

If yes, number of packs per day

Does your child drink alcohol?

Yes

Don't know

Does your child use street drugs?

Yes

Don't know

If yes, which ones?

Does your child drink beverages containing caffeine?

Yes

If so, list type of beverage and amount consumed daily:

Does your child take any over the counter medications?

Does your child take vitamins/food supplements?

Yes

If so, which ones?

Does your child engage in any of the following?

Does your child complain of feeling sick a lot?

Yes

How often does your child exercise?

Examples: None, how many times per week, per month

Mental Health History

Has your child ever had mental health counseling?

Yes

Did it help?

Yes

Date

Counselor

Has your child ever thought about trying to harm or kill himself/herself?

Yes

Do Not Know

If yes, what thoughts did they express?

Has your child ever tried to harm or kill himself/herself?

Yes

When?

How?

Child & Teen Checklist of Characteristics

Name

Date

Age

Person Completing This Form

Attention

Dawdles, procrastinates, wastes time

Distractible, inattentive, poor concentration, daydreams Interrupts, talks out, yells

Lack organization, unprepared

Low frustration tolerance, irritability

Over active, restless, fidgety, noisiness

Family

Difficulties with parents’s partner/new marriage/new family

Disrupts family activities

Recent move, new school, loss of friends

Relationships with sisters/brothers or friends/peers

Death in the family/bereavement

School

Failure in school

Complains of teachers not liking her/him?

Behavioral problems at school

Learning problems

Developmental delays

Please look back over the concerns you checked off and choose the one which you most want your child to be helped with. Which one is it?

Development Milestones

Mothers Pre-Natal Health? Describe if relevant

Drug/alcohol use

Medications used

Complications

At what age did your child:

Sit up?

3-6 months

6-9 months

9-12 months

Over 12 months

Crawl?

6-12 months

13-18 months

Over 18 months

Walk?

Under 12 months

12-18 months

18-24 months

Over 24 months

Make Vocal Sounds?

3-6 months

6-9 months

9-12 months

Over 12 months

Put two words together?

9-12 months

13-15 months

16-14 months

Over 24 months

Speak in multiple work sentences?

12-15 months

16-18 months

19-24 months

Over 24 months

Toilet trained?

Child Name

Date

Has your child ever had any accidents resulting in injuries? (broken bones, severe cuts or bruises, stomach pumped, head injury, eye injury, lost teeth, had stitches, loss of consciousness, etc.)

Yes

Do you have any concerns about your child’s current health?

Yes

If so, what concerns do you have?

Hearing

Vision

Speech

Gross motor coordination (walking/running/climbing)

Fine motor coordination (writing, closing buttons, etc.)

Sensory processing

Other

If other, please describe

Does your child have bladder control problems?

Yes

Does your child have bowel control problems?

Yes

Has there been a history of alleged child abuse for this child’s family? (physical, sexual, and /or emotional abuse, neglect)?

Yes

Have there been any family stressors within the past 12 months? (divorce, separation, change in residence, death in the family, family financial or legal difficulties)

Yes

If yes, please describe

Has your child ever been enrolled in a special education program or received any type of individualized educational services?

Yes

Additional Comments

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