child (15 yrs and younger) - the riverwalk group · page 1 of 8 child (15 yrs and younger) date...

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Child(15yrsandyounger) Dateformcompleted:

Pleaseprovidethefollowinginformationaboutyourchildandanswerthequestionsbelow.Informationyouprovidehereisprotectedasconfidentialinformation.Ifyouratherdiscussaquestionatthefirstvisit,pleasenotethat.

Child’sName:Last First MI

BirthDate:______/______/________Age:_______Gender�Male�Female�

NameofParent/Guardian#1 Last First MI

NameofParent/Guardian#2

Last First MI

OtherParent(s)/Guardian(s)involvedwithChild:(Step-parent,Live-InPartneretc.)

Name/RelationshiptoChild: Last First MI

Name/RelationshiptoChild:

Last First MI

PrimaryAddressforChild:

Number/Street

City State Zip

ContactinfoforParent/Guardian:*

HomePhone:( ) Mayweleaveamessage? � Yes�No

Cell/OtherPhone:( ) Mayweleaveamessage? � Yes�No

Email: Mayweemailyou? � Yes�No

*ifyouwouldliketoaddothercontactinformationforadditionalparents/guardianspleaseaddonbackofpageinsameformat.

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CurrentFamilySituation:

Whocurrentlyresidesinthehomewiththechild?

Wherehaschildlivedthroughouttheirlifeandwithwhom?

Maritalhistoryofthebiologicalparents:�Married�Separated�Deceased�Divorced�NeverMarried

DoeschildhaveStep-Mother?�Yes�NoDescribetherelationship:

DoeschildhaveStep-Father?�Yes�NoDescribetherelationship:

Ifchilddoesn’tlivewithbothparentsorhasauniquelivingarrangement,pleasedescribe:(ei:whohasprimarycustody,visitingschedulesetc.)

Hasthechildeverbeenplaced,boardedorlivedawayfromthefamily?�Yes�NoIfYes,explaincircumstances:

Aretherecurrentlyanymajorfamilystressors?�Yes�NoExplain:

Arethereanyotherfamilymemberslivinginthehome:�Yes�No

NameofFamilyMember

LivinginHome

Relation

toChild

IfSibling

Full/Half/Step/Other

RelationshipwithFamilyMember?

Good/Fair/Discord

� Good�Fair�Discord

� Good�Fair�Discord

� Good�Fair�Discord

� Good�Fair�Discord

� Good�Fair�Discord

� Good�Fair�Discord

� Good�Fair�Discord

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Ifthechildisadopted:

Agewhenchildcameintothehome:____________DateofLegaladoption:

Reasonandcircumstanceforadoption:

Whathasthechildbeentold?

Whenwasthechildtold?

HealthoftheFamilyMembers:Listallthefamilymembersandhowrelatedtotheclientwhohaveahistoryofanyofthefollowingpsychologicalproblemsorotherhealthproblems.

Issue Yes No ListFamilyMember/Howrelated

Alcohol/SubstanceAbuseAnxietyDepressionDomesticViolenceEatingDisordersObesityObsessiveCompulsiveBehaviorSchizophreniaSuicideAttemptsADHDMoodDisorders(“Bipolar”)BehaviorProblemsOtherpsychologicalproblemsOtherhealthissues

Additionalinformationaboutfamilyyouwishtoshare?

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CurrentConcerns:

Whyareyouseekingcounselingforyourchild?

Howlonghavetheseproblemsbeenoccurring?

Arethereanylifechanges/stressfuleventsyourchildorfamilyhavebeenexperiencingrecently?�Yes�No

Isyourchildcurrentlyexperiencingoverwhelmingsadness,griefordepression?�Yes�NoIfyes,for

approximatelyhowlong?

Isyourchildcurrentlyexperiencinganxiety,panicattacksorhaveanyphobias?�Yes�NoIfyes,when

didyoubeginexperiencingthis?

Isyourchildcurrentlyexperiencinganychronicpain?�Yes�NoIfyes,pleasedescribe:

Whereyouoryourchildreferredbyanyone?�Yes�NoIfyes,who?

GeneralandMentalHealthInformation

Howwouldyourateyourchild’scurrentphysicalhealth?

� Poor�Unsatisfactory�Satisfactory�Good�VeryGood

Pleaselistanyspecifichealthproblemsyourchildiscurrentlyexperiencing:

Hasyourchildpreviouslyreceivedanytypeofmentalhealthservices?(psychotherapy,psychiatricservices,etc.)

� Yes�NoPrevioustherapist/practitioner(s):

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Hasyourchildeverbeenadmittedtoapsychiatrichospital?�Yes�NoIfyes,Listbelow:

Age

admitted Facility

How

Long Reason/diagnosis Recommendations/Medications

*Pleaselistadditionalinformationonthebackofsheetifneeded.

Howwouldyourateyourchild’scurrentsleepinghabits?

� Poor�Unsatisfactory�Satisfactory�Good�VeryGood

Pleaselistanyspecificsleepproblemsyourchildiscurrentlyexperiencing:

Doesyourchildparticipateinphysicalactivity?�Yes�No

Pleaselistanydifficultiesyourchildmightbehavingwithappetiteoreatingpatterns:

Areyouconcernedyourchildisusinganyrecreationaldrugsoralcohol?�Yes�No

Isyourchildcurrentlytakinganyprescriptionmedications?�Yes�NoIfyes,pleaselistandreasonfortaking:Medication Reason

Hasyourchildeverbeenprescribedpsychiatricmedications?�Yes�NoIfyes,pleaselistandproveddates:Medication Approximatedates

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Hasyourchildeverseenamedicalspecialistforanothermedicalproblem?(endocrinologist,neurologist,

geneticsetc.)�Yes�NoIfyes,pleaselist:

Age DoctorName/Specialty

How

Long Reason/diagnosis Recommendations/Medications

*Pleaselistadditionalinformationonthebackofsheetifneeded.

NameofPediatrician:(Ifmorethanone,pleaselistall)

Name City,State DatesPatientthere

Name City,State DatesPatientthere

Name City,State DatesPatientthereIfyouwishtohaveyourprimarycaredoctorcontactedpleaseletusknowsothatappropriateformscanbefilledout.Doyouwantinformationtobesharedwithyourprimarycaredoctor?�Yes�No

DevelopmentalHistory:

NormalPregnancy?�Yes�No LengthofPregnancy: weeks

Ifcomplicationswithpregnancy,explain:

BirthWeight:________BirthLength:__________DeliveryType:�Vaginal�Cesarean�Induced�Breech

Anycomplicationswithdeliveryand/orafterbirth(NICUstay?)�Yes�NoExplain:

Didmothertakeanyprescribedordrugsofabuseduringpregnancy?�Yes�NoExplain:

Describeyourchild’sinteractionswithsiblingandpeers:

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Describeanyofyourchild’sspecialhabits,fearsoridiosyncrasies:

EducationalHistory:

NameofSchool City/State DatesAttended

Grades

Attended

*ifyouneedadditionalspacepleaseyoubackofform

Isyourchildenrolledinanyspecialeducationorspeciallymodifiedclasses?�Yes�NoIfyes,explain:

Hasyourchildeverbeenretainedorskippedagrade?�Yes�NoIfyes,explain:

Doesyourchildattendschoolonaregularbasis?�Yes�NoIfno,explain:

Doyoufeelyourchildismotivatedtoattendschool?�Yes�No

Whatisyourchild’sfavoriteclass?

Whatisyourchild’sleastfavoriteclass?

Hasyourchildeverbeensuspendedorexpelled?�Yes�NoIfyes,explain:

Doesyourchildparticipateinextracurricularactivities?�Yes�NoIfyes,explain:

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Other:

Doyouconsideryourchildand/orfamilytobespiritualorreligious?�Yes�No

Ifyes,describeyourfaithorbelief?

Whatareyourchild’shobbiesandinterests?

Whatarethechild’sstrengthsandtalents?

Whatwouldyouliketoaccomplishoutoftherapy?

Anythingelseyouwouldliketoshareorlettheclinicianknowaboutyourchild/situation?

Nameofpersonfillinginform: RelationshiptoChild:

Signature: Date:

TherapistSignature: Date:

1

PracticePoliciesandProcedures

Weoffercomprehensiveservicesforchildren,adolescents,adults,andfamilies.Ourpracticeiscomposedofspecialiststrainedindifferentmodalitieswhocaneffectivelymanagethediverseaspectsofpsychiatricneeds.Weofferawiderangeofservicesandin-depthevaluations.Pleaserefertoourwebsiteforacompletelistingofourservicesandmodalitiescurrentlyoffered.Yourpractitionerwillworkcloselywithyoutodevelopatreatmentplanthatmeetsyourspecificneeds.

Appointments

AllappointmentsmustbescheduleddirectlywiththeClinician.SomeCliniciansuseanonlineschedulingsystemandyouwillbesetupwithanusernameandpasswordifthisisavailabletoyouatthefirstsession.Thesessionlengthwillvarydependingontheservicesrequired.

Ifyoufailtocancelascheduledappointment,wecannotusethistimeforanotherclientandyouwillbebilledfortheentirecostofyourmissedappointment.Afullsessionfeeischargedformissedappointmentsorcancellationswithlessthana24-hournoticeunlessitisduetoillnessoranemergency.Thankyouforyourconsiderationregardingthisimportantmatter.

Confidentiality

Themedicalrecordsofourclientsarehighlyconfidential.Informationcontainedintherecordswillnotbereleasedwithoutproperwrittenconsent.Whentreatingachildoradolescent,parentsarekeptinformedofthegeneralprogressoftreatmentbutspecificandpersonalinformationiskeptconfidential.Inthecaseofadivorcesituationwheremedicalcustodyisshared,consentandauthorizationregardingdisclosureofanyinformationisrequiredfrombothparents.

ContactingOurOffice

PhoneCalls

Ifyouhaveanemergency,pleasereachouttoyourclinician,ifyoudonothearfromthemimmediately,gotoyournearestemergencyroom.Ourofficenumberis203-329-3759andeachclinicianhasavoicemailboxthroughthatnumber.Allphonemessagesarerespondedtoasquicklyaspossible.Besuretoleaveyourname,phonenumber,andconvenienttimeswhenyoucanbereached.Donotleavesensitivemedicalinformationonvoicemail.

PracticePoliciesandProcedures,revised5/1/2019

PracticePoliciesandProcedures,revised5/1/2019 2

Email

Youcanalsoreachyourindividualclinicianbyemail.Youcanfindtheiremailaddressonourwebsiteontheirindividualpages.Emailaddressesareallstandardizedtobethefirstletteroftheclinician’sfirstnameplustheirlastnamethen@theriverwalkgroup.com.Duetoprivacyconsiderations,wedonotdiscussclinicalmattersviatheinternetoremail.Wewilloccasionallysendfollow-upemailsthatpertaintoscheduling,billing,orotheradministrativemattersthatdonotincludeanysensitivemedicalinformation.Ifyouhaveaclinicalmatterthatneedstobediscussedbetweensessions,pleasecontactyourcliniciantoarrangeameanstodiscussfurther.

Fees/PaymentInformation

Forfurtherinformationonfeespleasespeakdirectlytoyourclinician.Attachedtothispacketisa“FormofPayment”sheettobecompletedtoalertushowyouwillbesettlingyourinvoices.TheRiverwalkGroupacceptsmultipleformsofpayment.Weaccepthealthsavingsaccounts,cash,checks,banktobankdepositsandcreditcards.

Insurance

TheRiverwalkGroupisanoutofnetworkprovider,whichmeansthatyoupayTheRiverwalkGroupdirectlyaftereachsession.Thisalsomeansthatwedonotparticipatewithanyinsurancecompanies.TheRiverwalkGroupwillprovideyouwithapaidinvoiceaftereachsessionthatincludesallnecessarycoding,datesandconfirmationofpaymentsothatyoucansubmittoyourinsurancecompany.Itisveryimportanttousthatourclientsreceivethemaximumreimbursementfromtheirinsurancecompaniesandwewillhelpinanywaypossibletoensurethisprocessisefficientandstraightforwardforourclients.Werecommendthatyoubeginexploringthisprocessasearlyasbeforethefirsttherapysessionorconsultation.

QuestionstoaskyourinsurancecompanywheninquiringaboutOut-of-NetworkBenefits:

• Does my plan cover out-of-network behavioral/mental health?• Whataremyout-of-networkmentalhealthbenefits?• DoIhaveadeductible?Ifso,whatisit?• Whatisthecoverageamountpertherapysession?• Istheamountpaidtomebasedontheactualfeeorbasedonwhatisconsideredreasonable

andcustomary?• Howmanytherapysessionsdoesmyplancover?• Istherealimittomycoverage?• Isareferralrequiredfrommyprimarycarephysician?• WhatinformationdoesTheRiverwalkGroupneedtoprovidetoreceivereimbursement?

PracticePoliciesandProcedures,revised5/1/2019 3

Tipstohelpwithgettinginsurancereimbursement:

Werecommendthatyoucreateapaperfileforallyourclaims.EachtimeaninvoicecomestoyoufromTheRiverwalkGroup,youshouldprintit,makeacopyandattachittoaclaimformfromyourinsurancecompany.Keepacopyoftheclaimformandinvoiceandmarkthedateyousentit.Werecommendthatyoufilloutthenecessaryitemsinthehealthformandmakemultiplecopiessothatitiseasilyaccessibleandissimpletoattachourinvoicetoit.Mail,scanorfaxtoyourinsurancecompany.Ifyouhavenotheardfromthemintwoweeks,calltoconfirmthattheyhavereceivedtheclaim.Additionally,makeacopyofyourinsurancecardtohaveinthefile.Makesureyoucopyboththefrontandbackofcard.

VisitingOurOffices&Parking

AlltheRiverwalkGroupCliniciansseepatientsatourlocationinStamfordConnecticutatthePhillipsMansionat666GlenbrookRoad.Themansionsitsinacomplexcalled“Riverwalk”andissurroundedbytownhouses.Whenyouentertheparkinglot,pleaseparkinaspacethatsaysAPG,MansionorES.APGspacesareinfrontofthemansion,ifyouarefacingthemansion,thespacesaretotheright.Thereareadditionalspaceslocatedinthebackofthemansionaswell.Ifyouparkintheback,youcanwalkupthestepstothefrontdoororaskyourclinicianaboutusingourbackentrance.

Pleasedonotparkinspaceswithnumbers.Thesearefortheresidentsthatliveinthetownhouses.Additionally,pleasedonotparkinspacesthatsayM.Sankoranyothername,asthesebelongtoourneighborsandarefortheirstaffandclients.

Whenyouenterthefrontdoorofthemansion,headstraightbackthroughthefoyertothedoorontherightnextto“TheRiverwalkGroup”sign.Onceinouroffices,headdownhallwaytothewaitingroom.Yourclinicianwillcometogetyouatthetimeofourscheduledappointment.Feelfreetohelpyourselftocomplimentarycoffee,teaorwaterwhileyouwait.Asthereareseveralconsultationroomsnexttothewaitingarea,werespectfullyrequestthatyoukeepconversationstoaminimumandallowthewaitingareatobeaquietspace.

Payment Policies for The Riverwalk Group

The Riverwalk Group provides psychotherapy, yoga therapy, group therapy, workshops and programming. Payment is expected at the end of each session unless other arrangements have been previously made.

The following options are available for payment:

� Cash or Check at time of visit � Credit card payment. A service fee of 3.5% will be added for credit card transactions. � Email Invoicing (NOTE: In order to participate in this option, payment must be received within

48 hours of receipt of invoice and a credit card must be on file with us. * If payment is not received within the 48 hours you are authorizing The Riverwalk Group to charge the credit card on file)

I, (First and Last Name) have read the above policy and understand that payment is due at the end of each session by check, cash or credit card.

If payment is not received as mentioned above, then you have my permission to charge my credit card as written below and/or on file.

Signature:

Today’s Date:

Name on Card:

Billing Address Credit Card:

Type of Credit Card:

Card Number:

Expiration Date:

Security Code:

*Note: Information written here will be entered to a secure system that will store your credit card in a way that is encrypted and not accessible except under the appropriate circumstances to make a payment. This paper will be destroyed after this information is transferred. The credit card information is NOT stored anywhere in our offices.

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NoticeofPatientPrivacyPracticesandRights

LimitsofConfidentiality

Theconfidentialityofyourpersonalhealthinformationisveryimportanttous.Contentsofalltherapysessionsareconfidential.Bothverbalinformationandwrittenrecordsaboutaclientcannotbesharedwithanotherpartywithoutthewrittenconsentoftheclientortheclient’slegalguardian.Ifyouhaveanyquestionsorconcerns,pleasefeelfreetodiscusswithyourclinician.Itisimportanttousthatyouunderstandthisprivacynoticeanditsclinicalimplications.

DutytoWarnandProtectWhenaclientdisclosesintentionsoraplantoharmanotherperson,thementalhealthprofessionalisrequiredtowarntheintendedvictimandreportthisinformationtolegalauthorities.Incasesinwhichtheclientdisclosesorimpliesaplanforsuicide,thehealthcareprofessionalisrequiredtonotifylegalauthoritiesandmakereasonableattemptstonotifythefamilyoftheclient.

AbuseofChildrenandVulnerableAdultsIfaclientstatesorsuggeststhatheorsheisabusingachild(orvulnerableadult)orhasrecentlyabusedachild(orvulnerableadult),orachild(orvulnerableadult)isindangerofabuse,thementalhealthprofessionalisrequiredtoreportthisinformationtotheappropriatesocialserviceand/orlegalauthorities.

PrenatalExposuretoControlledSubstancesMentalHealthcareprofessionalsarerequiredtoreportadmittedprenatalexposuretocontrolledsubstancesthatarepotentiallyharmful.

Minors/GuardianshipParentsorlegalguardiansofnon-emancipatedminorclientshavetherighttoaccesstheclients’records.

InsuranceProviders(whenapplicable)Insurancecompaniesandotherthird-partypayersaregiveninformationthattheyrequestregardingservicestoclients.Informationthatmayberequestedincludes,butisnotlimitedto:typesofservice,dates/timesofservice,diagnosis,treatmentplan,descriptionofimpairment,progressoftherapy,casenotes,andsummaries.

Iagreetotheabovelimitsofconfidentialityandunderstandtheirmeaningsandramifications.

ClientSignature(Client’sParent/Guardianifunder18) Date

ACKNOWLEDGEMENTOFRECEIPTOFHIPAANOTICEOFPRIVACYPRACTICES

IacknowledgethatIhavereceived/reviewedand/orreadtheHIPAANoticeofPrivacyPracticesincludingtheLimitsofConfidentiality.

Signatureofpatientor PrintedName DateRepresentative

Ifpersonalrepresentative’ssignatureappearsabove,pleasedescribePersonalRepresentative’srelationshiptothepatient.

Witness PrintedName Date