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103 Rossmore Pl.
Augusta, GA 30909
Office (706) 364-7165
Fax (706) 869-7600
Transitions of Augusta M. Kevin Turner, Ph. D. Licensed Psychologist GA License: 1589
We have enclosed our new patient paperwork and directions to our office.
Please complete the packet PRIOR to the appointment. If you need to cancel
or reschedule an appointment please do so 48 hours PRIOR to the
appointment.
Patients are responsible for bringing insurance cards to the
appointment. If you do not have a copy of the card it is the
patient’s responsibly to obtain that PRIOR to the
appointment.
Please be advised that it is ALWAYS a patient’s responsibility to contact their
insurance company to check their Mental Health Benefits and to verify if a
Provider is in network PRIOR to their appointment.
The information you may need to verify this is listed below:
Maxwell Kevin Turner Ph.D. Tax ID: 134268905
**Please note that if you are presenting with a minor patient and are not the
biological parent, you must bring legal documentation of
guardianship/custody status and/or signed authorization from the
parent/guardian granting you permission to treat the child.
We look forward to seeing you at your appointment.
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Client Information (Please print clearly and complete ALL blanks)
_________________________________________________________ ___________ _____ _______ ______ Last Name First Middle Date of Birth Age Gender Race ________________________________________________ ____________________________________________ Home Address Apt. City State Zip Code _____________________________ _________________________ ____________________________________ Best Contact Number Alternate Phone Number Email Address ______________________________ ___________ ______________________________________________ Social Security Number Martial Status Employer/School _____________________________ _______________________ ________________ _______________________ Primary Care Physician Emergency Contact Phone Number Relationship
Parent/Legal Guardian Information
Mother/Legal Guardian: _____________________________ Best Contact Number:_________________
Father/Legal Guardian: ______________________________ Best Contact Number: _________________
Primary Insurance Information ______________________________ ____________________________ ________________________ Policy Holder’s Name Insured SSN (if different from above) Subscriber Date of Birth
__________________________ ______________________________ ____________________________
Relationship to Patient Insurance Company Policy Number
Secondary Insurance
______________________________ ____________________________ ________________________ Policy Holder’s Name Insured SSN (if different from above) Subscriber Date of Birth
__________________________ ______________________________ ____________________________
Relationship to Patient Insurance Company Policy Number
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Child History PARENT QUESTIONNAIRE Date: ___________________________
Family Data (to be filled out by parents)
Child’s Name: _______________________________ Birthdate: _________ Age: ______ Grade: _______
Father’s Name: ______________________________ Age: __________ Education: __________________
Father’s Employer: _____________________________________________________________________
Mother’s Name: _____________________________ Age: __________ Education: __________________
Mother’s Employer: ____________________________________________________________________
Parents are: Married ____ Divorced ____ Separated ____ Widowed ____ Single ______
Date _______ Date ________ Date _________ Date ________ Date _______
Child lives with: Both Parents _____ Mother _____ Father _____ Other _____
Is this a foster home placement? Yes_____ No _____ Adopted? Yes _____ No ______
List the Names, Ages, And Highest Grades Attended of Siblings:
Sibling Name Age Highest Grade Attended
List other Relatives or People Living at Home:
Name Relation
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PREGNANCY HISTORY- MOTHER
During this pregnancy did you have? Yes No When Describe
Medication during pregnancy?
Emotional problems?
Threatened miscarriage or early
contractions?
Alcohol, drugs, tobacco use?
Other medical problems?
BIRTH HISTORY
How long was labor? ___________________________________________________________________
Was the delivery unusual in any way? Yes________ No_______ If yes how? ______________________
Did you have a cesarean? Yes_________ No_________ Complications? ___________________________
Was the baby’s color normal? Yes________ No_______ Blue? ______ Yellow? ______ Don’t know_____
Was the baby premature? Yes________ No_______ How much? ________________________________
Did you take the baby home with you from the hospital? Yes______ No______ How long after? ______
DEVELOPMENT (indicate child’s age)
Walked: ________________ Made Sounds: _____________ First spoke: __________________________
First Short Sentences: _____________________________________ Out of diapers: _________________
Any period of failure to grow or unusual growth? _____________________________________________
Do you consider your child’s speech and language development similar to other children’s?
Yes__________ No___________ If No, please explain: ________________________________________
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MEDICAL HISTORY
Yes No When Describe
Hospitalizations
Allergies (especially to
medicine)
Major Illness
Frequent accidents requiring
doctor’s care
Current Medications
Do you consider your child’s activity and energy level to be: Low_______ Average________ High______
As compared with other children of the same age, do you think your child’s general development is:
Below Average?______________ Average?__________________ Above Average? __________________
Describe child’s appetite and eating habits at present: _________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe child’s sleeping pattern now. Are there nightmares or night terrors now or in the past?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What have you found to be the most effective form of discipline? _______________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Is the discipline at home handled mostly by: Mother_________________ Father_________________
Describe how the child reacts to discipline. Any stubbornness? __________________________________
_____________________________________________________________________________________
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How does your child get along with children not in the family? A leader? Follower? Playing with children
who are older? Younger? ________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What is the age and sex of your child’s favorite playmate? _____________________________________
Describe any moody periods: _____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe any problems with awkwardness or clumsiness: ______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe any problems in sitting still or paying attention: ______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
EDUCATIONAL INFORMATION
School Attending: ___________________________________ Teacher: ___________________________
Child’s Present Grade: _________________ Has child repeated a grade? __________________________
Have there been many changes in the child’s school setting? Yes__________ No___________
If Yes, Explain: _________________________________________________________________________
_____________________________________________________________________________________
Did the child have difficulty leaving home or parents upon entering pre-school or first grade?
Yes__________ No___________ If Yes, explain: ______________________________________________
_____________________________________________________________________________________
Did he/she enjoy and feel successful in school? ______________________________________________
Please explain: ________________________________________________________________________
_____________________________________________________________________________________
Has/does your child receive special education services or private tutoring? ________________________
_____________________________________________________________________________________
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PHYSICIAN INFORMATION
When did the child last have a physical examination? _________________________________________
Is the child taking any form of medication? Yes________ No__________ If yes, what kind and the
reason: ______________________________________________________________________________
_____________________________________________________________________________________
Name of Pediatrician or Physician: _________________________________________________________
Have there been any previous psychological evaluations? Yes _______________ No________________
If yes, please indicate the following: Date of Evaluation:_________________ Provider:_______________
Diagnosis: ____________________________________________________________________________
Have there been any previous psychiatric, neurological, CT, MRI, or EEG evaluations? Yes_____ No_____
If yes, please indicate the following: Date of Evaluation:_________________ Provider:_______________
Diagnosis: ____________________________________________________________________________
What do you think are your child’s major problems? __________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
When did you first notice your child’s problems? _____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
In what ways do you think this clinic could be most helpful with your child? _______________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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ON THE FOLLOWING, PLEASE CHECK ALL THE ITEMS LISTED BELOW THAT APPLY
TO YOUR CHILD. IF YOUR CHILD IS ON MEDICATION NOW, PLEASE ANSWER
BASED ON PRE-MEDICATION BEHAVIOR.
OPPOSITIONAL DEFIANT DISORDER (ODD)
A pattern of negativistic, hostile, and defiant behavior lasting at least six months, during which four of
the following items are present.
□ Often loses temper
□ Often argues with adults
□ Often actively defies or refuses to comply with adult’s request or rules
□ Often deliberately annoys people
□ Often blames others for his or her mistakes or misbehavior
□ Is often touchy or easily annoyed by others
□ Is often angry and resentful
□ Is often spiteful and vindictive
GENERALIZED ANXIETY DISORDER
The anxiety and worry are associated with three (or more of the following six symptoms, with at least
some symptoms present for more days than not for the past six months). Note: Only one item is
required in children.
□ Restlessness or feeling keyed up or on edge
□ Being easily fatigued
□ Difficulty concentrating or mind going blank
□ Irritability
□ Muscle tension
□ Sleep disturbance
□ Racing thoughts
□ Headaches
□ Stomach aches
□ Dizziness
□ Blurring vision
□ Trouble breathing
□ Heart racing
□ Excessive sweating
□ Ringing in ears
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DYSTHYMIA
Presence (while depressed) of two of the following six symptoms.
□ Poor appetite or overeating
□ Insomnia or hypersomnia
□ Low energy or fatigue
□ Low self-esteem
□ Poor concentration or difficulty making decisions
□ Feelings of hopelessness
ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
Six or more of the following symptoms of inattention have persisted for at least six months to a degree
that is maladaptive and inconsistent with developmental level.
INATTENTION
□ Often fails to give close attention to details or often makes careless mistakes in schoolwork,
work, or other activities.
□ Often has difficulty sustaining attention in tasks or play activities.
□ Often does not seem to listen when spoken to directly
□ Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in
the workplace.
□ Often has difficulty organizing tasks and activities
□ Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
□ Often loses things necessary for tasks and activities
□ Is often easily distracted by extraneous stimuli
□ Is often forgetful in daily activities
Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least six months
to a degree that is maladaptive and inconsistent with developmental level.
HYPERACTIVITY
□ Often fidgets with hands or feet or squirms in seat
□ Often leaves seat in classroom or in some situations in which remaining seated is expected
□ Often runs about or climbs excessively in situations in which it is inappropriate
□ Often has difficulty playing or engaging in leisure activities quietly
□ If often “on the go” or often acts as if “driven by a motor”
□ Often talks excessively
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IMPULSIVITY
□ Often blurts out answers before questions have been completed
□ Often has difficulty awaiting turn
□ Often interrupts or intrudes on others
ADDIONTIONAL COMMENTS: ____________________________________________________
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By signing below I am swearing that I am the legal guardian of this child:
___________________________________________________________________Parent or Legal Guardian signature Date
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AUTHORIZATION FOR RELEASE OF INFORMATION (Please print)
Patient Name: _________________________________________________________________________ SSN#: ______________________________ Date of Birth: ______________________________________
I hear by authorize M. Kevin Turner, Ph.D. to release to/or obtain from:
Name of Person/Agency: ________________________________________________________________ Mailing Address: _______________________________________________________________________ _______________________________________________________________________ Telephone Number: ____________________________ Fax Number: _____________________________
INFORMATION TO BE RELEASED/OBTAINED FROM MEDICAL RECORDS:
____ Face Sheet ____ Medication Records ____ Discharge Summary ____ X-Ray Orders ____ History & Physical ____ Physician Orders ____ Admission History/Mental Status Exam ____ EKG Notes ____ Psychological Evaluation (s) ____ Diagnosis ____ Education Evaluation (s) ____ Admission/Discharge Dates ____ Discharge/Aftercare Plan ____ Lab Reports ____ Physician Weekly Progress Reports ____ Treatment Plan (s) ____ Other (Please specify): ______________________________________________________________ _____________________________________________________________________________________ For the purpose of: _____________________________________________________________________
This consent is given freely and voluntarily. Any information shall be released by the recipient without my written consent, except as mandated by State and Federal Law. In the event that information is released by a third party to unauthorized persons, the undersigned hereby releases the provider from any and all liability for such unauthorized release. I understand I may withdraw this consent at any time. This consent will expire on _______________ or 90 days from the date below, or sooner at my election. _____________________________________________ _____________________________________ Patient’s Signature Date Signature of Legal Guardian Date _____________________________________________ ______________________________________ Signature of Witness Date Relationship to Patient
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AUTHORIZATION CONSENT TO TREAT A MINOR
I __________________________________________ am Parent/Legal Guardian of
_____________________________________ who is a patient of Kevin Turner
Ph.D.
Biological Mother’s Name: ____________________________________________
Biological Father’s Name: _____________________________________________
I am authorizing/refusing release of any medical information.
__________________________________________ Mother ( ) Authorized
( ) Not Authorized
__________________________________________ Father ( ) Authorized
( ) Not Authorized
__________________________________________ Other ( ) Authorized
( ) Not authorized
Signed by: __________________________________________________________
Date: ______________________________________________________________
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AUTHORIZATION CONSENT FORM
HIPPA AGREEMENT
The HIPAA Privacy Rule provides federal protections for individually identifiable health
information held by covered entities and their business associates and gives patients an array of
rights with respect to that information. At the same time, the Privacy Rule is balanced so that it
permits the disclosure of health information needed for patient care and other important
purposes. The Security Rule specifies a series of administrative, physical, and technical
safeguards for covered entities and their business associates to use to assure the
confidentiality, integrity, and availability of electronic protected health information. (See
www.transitionsofaugusta.com for additional details)
I have read and agree to the Patient Service/HIPPA Agreement provided to me by Transitions of
Augusta. I have read and understand the Georgia Notice of Psychologist’s Policies and Practices.
_____________________________________________________________________________________Signature Date
TREATMENT AUTHORIZATION
I ___________________________________________ (Patient Name) authorize M. Kevin
Turner Ph.D. to provide Psychological Services or Testing.
INSURANCE AUTHORIZATION
I authorize M Kevin Turner Ph.D. (Transitions of Augusta) the release of any medical or other
information necessary to process medical claims. I authorize payment of medical benefits to be
paid to M. Kevin Turner Ph.D. (Transitions of Augusta) for services provided.
_____________________________________________________________________________________
Signature Date
Cancelation Policy
I understand it is my responsibility to contact Transitions of Augusta 48 HOURS PRIOR to my
appointment to cancel or reschedule. I will be charged a $60 fee for missed appointments
without 48 hour prior notification.
_____________________________________________________________________________________
Signature Date
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Directions to Transitions of Augusta, P.C Kevin Turner, Licensed Psychologist
103 Rossmore Place, Augusta, GA 30909. (706) 364-7165
We are located behind the Double Tree Hotel (formerly the Sheraton) and next to the Augusta
Corporate Center (location of the IRS). Please allow extra time to locate the office.
From Blythe, Hephzibah, Deans Bridge, Tobacco Road area- Take U.S. 1
(Deans Bridge Rd.) to the 520 (Bobby Jones Expwy) Take 520 (Bobby Jones Expressway) west to Wheeler Rd. exit #1C and make a left at the stop light. Go ½ a mile and make a right at the 2nd stop light (across from the Waffle House) onto Perimeter Parkway. Follow Perimeter Parkway around the curve to Whitney Place (Between the Double Tree Hotel and the Augusta Corporate Center). Go about 0.2 miles, over a small hill and the offices will be to the right. (Rossmore Place; inside a small cul de sac) We are the office in the middle.
From Washington Rd., area – Take Washington Rd. to the 520 (Bobby Jones
Expressway). Take the 520 (Bobby Jones Expwy) about 2 miles to exit #1C Wheeler Road. Make a left at the traffic light and a right at the next traffic light (across from the Waffle House) onto Perimeter Parkway. Follow Perimeter Parkway around (pass the Montessori School of Augusta) and make a left onto Whitney Place (Between the Double Tree Hotel and the Augusta Corporate Center). Go about 0.2 miles and the building will be on the right (Rossmore Place; inside a small cul de sac) We are the office in the middle.
From South Carolina – Take I – 20 going westbound into Georgia. Take Exit
#196A towards 520 Bobby Jones Expressway. Take the 520 (Bobby Jones Expressway) to exit # 1C Wheeler Road. Make a left at the traffic light and a right at the next traffic light (across from the Waffle House) onto Perimeter Parkway. Follow Perimeter Parkway around (pass the Montessori School of Augusta) and make a left onto Whitney Place (Between the Double Tree Hotel and the Augusta Corporate Center). Go about 0.2 miles and the building will be on the right (Rossmore Place; inside a small cul de sac) We are the office in the middle.
From Downtown Augusta, Walton Way area – Take Walton Way to the
Walton Way Ext. and bear to the right. Make a left at the traffic light onto Wheeler Rd. and keep straight about 1 mile (Past O’Charlie’s). Make a right at the 4th traffic light (across from the Waffle House) onto Perimeter Parkway. Follow Perimeter Parkway around (pass the Montessori School of Augusta) and make a left onto Whitney Place (Between the Double Tree Hotel and the Augusta
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Corporate Center). Go about 0.2 miles and the building will be on the right (Rossmore Place; inside a small cul de sac) We are the office in the middle.
From Thomson, Grovetown, Lincolnton area – Take I-20 East to exit # 195
Wheeler Road. Make a right onto Wheeler Road for about 1mile. Make a left at the traffic light (across from the Waffle House) onto Perimeter Parkway. Follow Perimeter Parkway around (pass the Montessori School of Augusta) and make a left onto Whitney Place (Between the Double Tree Hotel and the Augusta Corporate Center). Go about 0.2 miles and the building will be on the right (Rossmore Place; inside a small cul de sac) We are the office in the middle.