Child/Teen Counseling Intake Form

Transcription

1 We would like to thank you for selecting FSS Behavioral Health and Wellness to provide support for your child. Our counselors are highly experienced, and are focused on helping children live happier, healthier lives. We strive to make sure your experience with us will be positive and will give you the help you are seeking. Your child s first counseling appointment will be set up for the soonest available opening. If your child is in crisis after office hours or on weekends, please contact 911 or Texas Panhandle Center s Crisis Line at or Getting Started: In this intake packet you will find the following: Client Information Forms: This is to be completed by the parent, guardian or family member. Important: If there are court documents regarding custody, please bring to the intake appointment. Insurance Policy: Please read and sign. Client Agreement: Please read and initial. HIPPA Notice of Privacy Practices: Please read and sign. After reviewing and completing the enclosed documents, contact us at to schedule an intake appointment.

2 Please note: Information you provide here is protected as confidential information. Today s Date Child s Name: (first) (middle initial) (last) Child s Date of Birth: Child s Current Age: Child s Social Security Number: Child s Address: (street) (apt. number) (county) (city) (state) (zip code) Child s Gender: Female Male Which category best describes your child s race, ethnicity, or origin: Native American or Alaska Native Asian Black or African American Hispanic, Latino, or Spanish origin Middle Eastern or North African Native Hawaiian or Pacific Islander White Other Child s Primary Language: English Spanish Other Full name of person completing questionnaire: Your Work Phone: May we call you here? Yes No Your Home Phone: May we call you here? Yes No Your Cell Phone: May we call you here? Yes No Page 2 of 12

3 Check any topic(s) you would like addressed in your child s counseling: Category I Category II Category III ADD/ADHD Loneliness Appetite Change Loss/Grief Abortion Anger Motivation Bedwetting Death Alcohol/Drugs Assertiveness School Anxiety Confusion Obsessions Pregnancy Autism Self Confidence Cruelty to Animals Physical Health Runaway Conduct Disorder Self-Image Divorce Sleep Sexual Abuse Defiant Separation Anxiety Eating Disorder Soiling Sexuality Depression Shyness Family Conflict Weight Loss/Gain Learning Disorder Social Skills Fire Setting Suicidal Thoughts Describe any other issues you would like addressed in your child s counseling sessions: SCHOOL HISTORY Where does your child attend school? Describe any school problems that your child is experiencing: PERSONAL HISTORY Has your child ever been hit, slapped, thrown or molested? By whom How many times? Last incident Yes No Have there been any serious illnesses, injuries, emotional problems, or deaths in the child s immediate family? Yes No If yes, please describe: Please describe any long-standing illnesses or medical conditions your child has Page 3 of 12

4 What medications is your child presently taking (include home remedies and overthe-counter drugs such as aspirin, etc.) Medication For History of Substance Abuse Age when your child first tried this drug Alcohol Cigarettes Cocaine Downers Ecstasy Heroin Inhalants LSD (acid) Marijuana Mushrooms PCP Methamphetamines including Crank, Crystal, Ice and Speed Synthetic marijuana, also known as K2 or Spice Has your child ever had a drug/alcohol related black out? Yes No If yes, where and when Has anyone in the child s family had a drug or alcohol addiction? Parent/Step-parent Sibling Grandparent Friend Child Other Page 4 of 12

5 FAMILY SUPPORT SERVICES Check any of the following that your child has experienced: Desire to Harm Self or Yes No Please Provide an Example Others Current desire to harm him/herself? Has child attempted to harm self before? Current desire to harm others? Has the child attempted to harm others in the past? Has your child had any previous counseling? Yes No If yes, where and when: Is your child currently in counseling? Yes No Who is their counselor? CHILD S FAMILY BACKGROUND Biological Mother s Name: Age: Occupation: Health concerns: If deceased, give her age at time of death: How old was the child? Cause of death: Biological Father s Name: Age: Occupation: Health concerns: If deceased, give his age at time of death: How old was the child? Cause of death: Page 5 of 12

6 Who else has helped raise the child? (for example, grandparents, adoptive parents, foster family, etc.) Guardian#1 Name: Age: Occupation: When did the child live with this person? Guardian #2 Name: Age: Occupation: When did the child live with this person? List names and ages of other guardians and when the child lived with them: Siblings Name 1) 2) 3) 4) 5) 6) 7) Natural? Half? Step? Gender Age Describe Relationship Deceased? At what age? Page 6 of 12

7 CLIENT AGREEMENT We want your experience at Family Support Services to be as beneficial as possible. It is helpful to know exactly what to expect and how our agency works. Read each section and initial by each heading. Counseling cannot begin until court order has been provided (if required) Confidentiality Confidentiality means keeping private your identity and the information you share with your counselor and/or other group members. On occasion, other Family Support Services employees or interns will have access to your file for agency teaching, supervision, research, treatment and administrative purposes. Interns or agency staff will also, on occasion, observe session(s). Furthermore, auditors from outside this agency may also access your records. Any person observing a session, group or your file is required to sign a statement, which requires them to respect your confidentiality. Exceptions To Confidentiality Your records could be subpoenaed by a court of law. If you are threatening to harm yourself or someone else. We must report suspected neglect or abuse of children, the handicapped or the elderly (we are required by law to notify the appropriate protective service. We encourage you to report any incidents personally). We must send reports to referring agents from the legal system (e.g., judge, district or county attorney, probation officer, or child or adult protective services caseworker). Cancellation We require a 24-hour notice for all cancellations. This courtesy gives us the opportunity to schedule other waiting individuals. Cancellation with less than a 24-hour notice will result in a charge of your session fee. If you have a reduced fee or a 3 rd party payment source (e.g. Medicaid or Insurance) cancellation with less than a 24-hour notice will result in a charge of $20 which you will be responsible for paying. Insurance The child does have insurance The child does not have insurance I have read and signed the Insurance Policy. Cost of Service Page 7 of 12

8 We are able to provide services to families and individuals by accessing United Way Funds, area grants, contracts, and by accepting third party payment sources such as insurance assignments and client fees to fund the services. We have a sliding scale fee based on gross household income (the amount before taxes or any deductions are taken out). According to my proof of income, the annual gross household income is. The fee will be set at your intake appointment. If you cannot afford the fee, a fee reduction request can be done. Fee is due at the time of service. We require written income verification to be in your file. The verification must be updated every five (5) months. Any change in circumstances must be reported as soon as possible. Your updated income verification and fee review will be completed. Assignment to Counselor Following an intake appointment, your case will be assigned to a counselor during a weekly staff meeting. You should expect to receive a call from a counselor within 1 2 weeks following your intake appointment. If you have not received a call within 2 weeks you should contact the Director of Behavioral Health and Wellness, Amy Hord, at After-Hours/Weekend Calls Family Support Services is not an emergency facility. You may access our 24-hour hotline at or Texas Panhandle Center s Crisis Line or If you have an emergency after office hours or on weekends, go to your hospital emergency room or call I,, understand and agree that,, will be involved in counseling/therapy/educational services at Family Support Services of Amarillo. I understand that I have the right to terminate services at any time. The fee for each session is $ and will be payable at the time of the session. If I am unable to keep my appointment, I agree to notify Family Support Services no later than 24 hours prior to my appointment. I understand that I will be charged and be responsible for any missed appointments that are not cancelled with 24 hours notice. I understand written verification of income is required and that I will notify Family Support Services of any changes in my circumstances. My signature indicates I have read, understood, and agree to abide by the Client Agreement. Name of Child s Guardian Staff Signature Signature of Child s Guardian Date Rev. JUNE2017 JW/SD Page 8 of 12

9 HIPAA NOTICE OF PRIVACY PRACTICES Family Support Services Effective Date: September 1, 2003 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS CAREFULLY If you have any questions about this notice, please contact Amy Hord, Privacy Officer of Family Support Services at or Our Pledge Regarding Health Information: Family Support Services understands that information about your health and health care is personal. We pledge to protect this confidential information about you. Family Support Services creates a record of the services and care you receive from us. This record is necessary to assure you of high quality services and is essential to comply with certain legal requirements. This Notice of Uses applies to all of the records of your care while at Family Support Services. The following notice tells you how we use and disclose health information about you. It also describes your rights to your information and certain obligations we have regarding the use and disclosure of your health information. Our Legal Duty: We are required by applicable federal and state law to maintain the privacy of your health information. We must provide you with a copy of this notice in regard to our legal duties and privacy practices. We must follow the privacy practices described in this Notice while it is in effect. We reserve the right to change our privacy practices at any time. You will be notified of changes in our privacy practices. How We May Use and Disclose Health Information About You: For Treatment. We may use or disclose your health information to provide you with health care treatment or services. This information may be shared with Page 9 of 12

10 therapists, supervisors, and other staff of Family Support Services participating in your care. For Payment. We may use and disclose your health information so that your treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or other third party. We may also tell your health plan about services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. For Health Care Operations: Information about you may be used or disclosed for the operation of our services. Health care operations include quality assurance and improvement activities, case management, evaluating the competence or qualifications of our staff, accreditation, licensing, conducting training programs, and supervision. Appointment Reminders: We may use and disclose personal information about you to contact you as a reminder that your have an appointment. Please let us know if you do not wish to have us contact you concerning your appointment or if you would like us to use a different telephone number of address for your reminder. Your Authorization: You may give us written authorization to disclose your health information to anyone for any purpose. As Required By Law: We may use or disclose your health information when we are required to do so by law. To Avoid a Serious Threat to Your Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. If we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose personal information about you in response to a subpoena, discovery request, or other lawful process. We will make a reasonable effort to contact you in regard to these requests. Client rights: Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. You may submit your request in writing to Amy Hord, Privacy Officer. If you request a copy of the information, we charge a fee for the costs of copying, mailing, or other supplies and services associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Family Support Services will appoint a health care professional to review your request and the denial. We will comply with the outcome of the review. Right to Amend. If you feel that the information about you is incorrect or incomplete, you may ask us to amend the information. You have this right to Page 10 of 12

11 amend as long as we store your record. To request an amendment, please submit your request in writing to Amy Hord, Family Support Services Privacy Officer. This request must be on one page of paper and must provide a reason that supports your request for an amendment. Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations as previously described. To request a list of disclosures, please submit your request in writing. A records fee may be charged for this list. Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice at any time. There is no charge for a copy of this Notice. Changes to this Notice We reserve the right to change this notice. This right extends to health information we already have about you as well as any information we will have in the future. A copy of our current notice will be posted in our agency. Complaints If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. Please submit those to Amy Hord, Privacy Officer. You will not be penalized for filing a complaint. Other Uses of Health Information Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us with permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. Acknowledgement of Receipt of this Notice We request that you sign a separate form acknowledging you have received a copy of this notice. This acknowledgement will be kept on file in our offices. Rev.July2017/sd/ah Page 11 of 12

12 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I,, have received a copy of Family Support Services Notice of Privacy Practices. Signature Date Page 12 of 13

13 Family Support Services of Amarillo, Inc South Polk ~ (806) Section I. Client Information Client Name: Date: Address: City: State: Zip: Primary Phone Number: ( ) Work Number: ( ) Cell Number: ( ) Date of Birth: Check Appropriate Box Minor (under 18 years of age) Social Security Number: Single Married Widowed Separated Divorced Section II. Responsible Party (person paying the bill) Relationship to Client: Self Spouse Parent Other **If self, please check mark the "Self" box and proceed to Section III Your Name: Relationship to Client: Social Security Number Date of Birth: Address (if different from Client's): Employer: City/State: Work Number: ( ) Zip: Section III. Name of Insured (as it appears on the card) Social Security Number: Insurance Information Name of Employer: Relationship to Client: Date of Birth: Employer Address: City/State: Zip: Work Number: ( ) Insurance Company: Group#: ID#: Insurance Company Address: Insurance Company Phone Number: ( ) ***Do you have any additional insurance*** Yes No ***If Yes, please complete the required information below*** Name of Insured (as it appears on the card) Relationship to Client: Date of Birth: Social Security Number: Name of Employer: Employer Address: City/State: Zip: Work Number: ( ) Insurance Company: Insurance Company Address: Group#: ID#: Insurance Company Phone Number: ( ) PLEASE NOTE: CLIENTS WHO HAVE MEDICAID WILL NEED TO PROVIDE ALL INSURANCE INFORMATION ** CLIENTS WHO HAVE MEDICARE WILL NEED TO PROVIDE SECONDARY INSURANCE INFORMATION ** PARENTS OF MINOR CHILD(REN) WILL NEED TO PROVIDE ALL INSURANCE COVERAGE FROM BOTH PARENTS ** IF REQUESTED INSURANCE INFORMATION IS NOT PROVIDED, THE PERSON LISTED ON SECTION II "RESPONSIBLE PARTY" OF THIS FORM WILL BE RESPONSIBLE FOR ALL FEES INCURRED. Page 13 of 13