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
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