Child Intake Form Adult Services CHILD/TEEN SERVICES Teletherapy Child Intake Form 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 Email 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 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 No Has your child been seen here before? Yes No 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 No If “yes” name or describe condition Your child’s health is: Excellent Good Fair Poor Does your child have any allergies? Yes No If yes, please list below by allergy, reaction and medications taken. Health Habits Does your child smoke cigarettes or use tobacco products? Yes No Don't know If yes, number of packs per day Does your child drink alcohol? Yes No Don't know Does your child use street drugs? Yes No Don't know If yes, which ones? Does your child drink beverages containing caffeine? Yes No If so, list type of beverage and amount consumed daily: Does your child take any over the counter medications? No Yes Aspirin/Tylenol/Ibuprofen Antihistamines Antacids Laxatives Sleeping pills Does your child take vitamins/food supplements? Yes No If so, which ones? Does your child engage in any of the following? Restrict food intake Binge eating Overeating Use laxatives Self induced vomiting Does your child complain of feeling sick a lot? Yes No 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 No Did it help? Yes No Date Counselor Has your child ever thought about trying to harm or kill himself/herself? Yes No Do Not Know If yes, what thoughts did they express? Has your child ever tried to harm or kill himself/herself? Yes No When? How? Child & Teen Checklist of Characteristics Name Date Age Person Completing This Form Mood Affectionate Concern for others Complains Cries easily, feelings are easily hurt Fearful Friendly, outgoing, social Moody Likes to be alone, withdraws, isolates Nervous Mute, refuses to speak Sad, unhappy Shy, timid Stubborn Suicide talk or attempt Worry Thumb sucking, finger sucking, hair chewing Angry rages Under active, slow moving, lethargic 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 Behavior Argues, “talks back” Swearing, foul language Cruel to animals Conflicts with parents over rules of the home Dependent, immature Legal difficulties truancy, vandalism, stealing, drugs Fire setting Extra curricular activities interfere with academics Independent Fighting, hitting, violent, aggressive, hostile Lying Immature, has only younger playmates Nail biting Lacks respect for authority Obedient Disobedient, uncooperative, refused, defiant Pouts Need for high degree of supervision Responsible Prejudiced, insulting, name calling, intolerant Truant, avoiding school Rocking or other repetitive movements Uncoordinated, accident prone Sexual: sexual preoccupation, inappropriate sexual behaviors Runs away Tics – involuntary rapid movements, noises, or words Bullies, intimidates, teases Teased, picked on, victimized, bullied 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? Under 1 year 1-2 years 2-3 years 3-4 years 4-5 years Over 5 years 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 No Do you have any concerns about your child’s current health? Yes No 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 No Does your child have bowel control problems? Yes No Has there been a history of alleged child abuse for this child’s family? (physical, sexual, and /or emotional abuse, neglect)? Yes No 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 No If yes, please describe Has your child ever been enrolled in a special education program or received any type of individualized educational services? Yes No Additional Comments reCAPTCHA If you are human, leave this field blank. Submit Where We Are Rock Landing Psychological Group, PLC The James Building 11825 Rock Landing Drive Newport News, VA 23606 Phone: (757) 873-1736 Fax: (757) 873-1028