Child Intake Form
Sex
Your Relationship to Client
Sex

THE OTHER PARENT IS:

INSURANCE INFORMATION

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.

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.

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.

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.

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

Referral Information

May we have permission to thank them for your referral?
Has your child been seen here before?

Legal Information

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

Check all which apply.

Brief Health Information

Prescription medications your child takes.

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

Is your child now being treated for any medical condition?
Your child’s health is:
Does your child have any allergies?

Health Habits

Does your child smoke cigarettes or use tobacco products?
Does your child drink alcohol?
Does your child use street drugs?
Does your child drink beverages containing caffeine?
Does your child take any over the counter medications?
Does your child take vitamins/food supplements?
Does your child engage in any of the following?
Does your child complain of feeling sick a lot?
Examples: None, how many times per week, per month

Mental Health History

Has your child ever had mental health counseling?
Did it help?
Has your child ever thought about trying to harm or kill himself/herself?
Has your child ever tried to harm or kill himself/herself?

Child & Teen Checklist of Characteristics

Mood
 
Attention
Family
School
Behavior
 

Development Milestones

Mothers Pre-Natal Health? Describe if relevant

At what age did your child:

Sit up?
Crawl?
Walk?
Make Vocal Sounds?
Put two words together?
Speak in multiple work sentences?
Toilet trained?
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.)
Do you have any concerns about your child’s current health?
If so, what concerns do you have?
Does your child have bladder control problems?
Does your child have bowel control problems?
Has there been a history of alleged child abuse for this child’s family? (physical, sexual, and /or emotional abuse, neglect)?
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)
Has your child ever been enrolled in a special education program or received any type of individualized educational services?