Bismarck Location Minot Location2625 N 19th Street 2080 36th Ave SW Suite 110Bismarck, North Dakota 58503 Minot, ND 58701

Phone: 701-222-3175Fax: 701-222-3186

www.reddoorpediatric.com

Counseling Services Intake Form (Child ages 0-12yrs.)

Our evaluation of your child will depend on information about his/her past history. Fill out this form as completely as possible and bring with you the day of the evaluation. If you have questions regarding any items, put a checkmark in the left margin and we can discuss them when you come for your appointment. Today’s date:_____________________

Person completing form (first/last name):________________________________________________

Relationship to child:________________________________________________________________

If you are not the child’s current legal guardian, please list the legal guardian: _________________________________________________________________________________

Type(s) of service desired: ❏ Child therapy❏ Adolescent therapy❏ Family therapy

IDENTIFICATION:

Name:

Gender:

Date of birth:

Age:

Ethnicity:

Child lives with:

Primary address:

City, State, Zip

Telephone: Home:Work:Cell:

Parent email:

Referred by : ❏ Parent/guardian❏ Pediatrician❏ School❏ EAP❏ CPS❏ Social Services❏ Court Order❏ Other: _____________________

Emergency Contact name:

Emergency Contact number:

Relationship:

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Consent for Child Treatment

I am the legal guardian of _________________________________________with full legal authority to consent to treatment. I give permission for Red Door Pediatric Therapy Counselors to provide treatment for this child which may include assessment advocacy, referral and mental health counseling.

Signature: ___________________________________________Date:___________________________

Print name:_______________________________________Relationship to child:__________________

Section 1: Reason for the Assessment

Child's main problem/major reason for seeking help at this time:

____________________________________________________________________________________

____________________________________________________________________________________

How long has your child had these problems, symptoms, or issues? ____________________________________________________________________________________

Has your child had treatment for these issues in the past? ❏ Yes, if so, was the outcome helpful?__________________❏ No

Has your child had inpatient mental health treatment?❏ Yes❏ No

Briefly describe treatment including dates, name of facility/therapist, presenting issues and outcome:

____________________________________________________________________________________

____________________________________________________________________________________

Describe any other behavioral or emotional problems your child is having:

____________________________________________________________________________________

____________________________________________________________________________________

Describe the impact of your child's problems on the family:

____________________________________________________________________________________

____________________________________________________________________________________

Describe your child's strengths and unique qualities:

____________________________________________________________________________________

____________________________________________________________________________________

Does this child have a history of abuse (physical, sexual, emotional, neglect)? If yes, please explain.❏ Verbal❏ Physical❏ Sexual

Is there any other legal action that may have impacted your child? Please check all that apply: ❏ Custody❏ Probation ❏ Visitation ❏ Adoption ❏ Child Protective Services

Section 2: Family Information

List all of the people who currently live with the child.

Name Age Relationship Occupation/School

If child lives between 2 homes, please provide information on the second household below:

Name Age Relationship Occupation/School

Do all sibling have the same parents? If no, please explain.________________________________________________________________________________________________________________________________________________________________________

Indicate if any family members have the following:

Self Parents Siblings Grand-Parents

Attention, activity or impulse control as a child

Learning disabilities

Alcohol/Drug Abuse

Problems with aggressive behavior as an adult or child

Legal Issues

Abuse victim

Depression/Anxiety

Other Mental Health Issues

Serious illness

Surgeries

Physical disabilities

Family Stresses: Check all that apply:

Topic Current In the past

Marital problems

Marital separation

Parental arguments

Domestic violence

Divorce

Legal issues

Financial problems

Job loss

Custody disputes

Housing Issues

Death of a pet

Death of a friend

Death of a relative

Family illness

Parent(s) using alcohol/drugs

Traumatic Events

Other stressors: If other stressors, please describe: ____________________________________________________________________________________

What are your family supports? (church, friends, clubs etc.)

____________________________________________________________________________________

____________________________________________________________________________________

What are your family strengths?

____________________________________________________________________________________

____________________________________________________________________________________

Additional comments:

____________________________________________________________________________________

____________________________________________________________________________________

Section 3: Behavioral Assessment Please check any of the following behaviors that concern you:

Behavior Currently In the past

Sadness

Depression

Temper outbursts

Loss of enjoyment of usual activities

Withdrawn

Irritability

Anger

Expressing a wish to die

Has threatened/attempted suicide

Injures self

Disobedience/Refuses to Listen

Bedtime fears

Won't sleep/Trouble going to sleep

Sleepwalking

Nightmares

Night terrors

Wakes up very early

Unable to go back to sleep

Tiredness

Fatigue

Restless sleep

Wakes frequently

Sleeps too much

Does things that annoy others

Worries more than others

Unusual fears or phobias

Panics/Anxious

Repeats unnecessary act over and over

Is overly concerned about things

Has rituals, habits, superstitions, obsessions

Twitches or unusual movements

Eats very little/fasts to lose weight

Gorges or binge eats

Easily annoyed by others

Blames other for own mistakes

Swears or uses obscene language

Low self-esteem

Wanting to run away

Sneaks out at night

Stealing

Lying

Hurts animals

Poor appetite

Destroys property

Hurts people

Overly active

Frequently acts without thinking

Doesn't finish things

Short attention span

Problems with authority

Daydreams

Fantasizes

Problems with the law

Easily distracted

Low motivation

Hallucinations

Vomits intentionally

Bedwetting/daytime wetting

Soiling (pooping) in pants

Strange or unusual behavioral

Disorientation

Forms of discipline used in the home: please check all that apply❏ Time out❏ Loss of privileges❏ Grounding❏ Rewards/incentives❏ Extra chores❏ Physical/corporal punishment❏ Other:

____________________________________________________________________________

Section 4: Developmental History

PREGNANCY/BIRTH HISTORY:Which pregnancy was this child?______________

Age of mother at child’s birth:_________________

Age of father at child’s birth:__________________

During pregnancy, did mother: ❏ drink/use drugs ❏ illnesses❏ accident ❏ problems with pregnancy ❏ problems with labor

❏ problems with delivery If yes, please describe:__________________________________________________________________________________________________________________________________________________

Length of pregnancy: Type of delivery:

Birth weight: Apgar scores:

Length of labor: Was labor difficult?

Was medical intervention needed during labor/delivery (if yes, please explain (ex. induction, forceps,

epidural, blood transfusion, etc.)?

_______________________________________________________________________________

____________________________________________________________________________________

Were there any bruises, scars, or abnormalities to the child’s head?

____________________________________________________________________________________

Did the child require oxygen? yes / no Was child “blue”? yes / no Was the child jaundice? yes /no

Were there any problems immediately following birth or during the first two weeks of the child’s life (ex.

NICU, nursing, swallowing, sucking, feeding, sleeping, etc.)? If so, describe:

____________________________________________________________________________________

____________________________________________________________________________________

DEVELOPMENTAL HISTORY: At what age did the child develop the following skills:

Rolled over alone: Sat alone: Crawled:

Stood alone: Walked unaided: Fed self with spoon:

Bladder trained: Bowel trained: Consumed solid foods:

First word: First phrase: Conversation:

Please check if child is/was delayed in any of the following areas:❏ holding head up ❏ turning over ❏ sitting up❏ crawling❏ walking alone❏ weaning❏ feeding self❏ toilet training❏ using single words❏ using sentences❏ dressing self❏ sleeping through night

As a baby/toddler, was child:

❏ eating well ❏ colicky ❏ head banging❏ performing rocking behavior❏ clumsy❏ easy to regulate (sleeping/eating)❏ wanting to be left alone❏ adaptable to transitions ❏ more interested in things than people❏ easy to soothe❏ performing daredevil behavior

In the first 2 years of life, did your child experience:❏ Separation from Mother/Father❏ Out of home care❏ Disruption from bonding❏ Depression of Mother❏ Abuse/neglect❏ Chronic pain❏ Parental Stress

Social/Relationship Development:Please check each item that applies:

Behavior Current In the past

Prefers to be alone

Is demanding and bossy

Is alone a lot, but dislikes this and feels lonely

Fights with others

Is shy

Bullies others

Has few friends

Teases a lot

Has many friends

Plays with younger kids

Plays with “problem kids”

Plays with older kids

Is picked on a lot

Poor relationships with peers

Is oversensitive

Conflict with parents/step-parents

Poor relationships with teachers

Has difficulty getting along with brothers and sisters

School Related Topics:

Your child’s school/daycare:: ____________________________________________________________Grade: ________________Teacher: ___________________________________________________________________________

Please check any area of concern:

Behavior Current In the Past

Dislikes school

Missed many school days

Works hard but does not do well

Repeated a grade

Unmotivated

Refuses to complete work

Discipline referrals

Detentions

Learning problems

Suspensions, if so how many? ________

Expulsions, if so how many? _________

School Environment: Check all that apply:

Programs Current In the past

Resource classes/special ed.

Continuation school

Gifted program

Home study

Speech therapy

Occupational therapy

Independent study

Other: __________________________________________________________________________________

Section 5: Medical HistoryPHYSICIAN INFORMATION:Child’s Primary Doctor:_________________________________________________________________

Indicate if your child has had any of the following:

Condition Y/N Details

Migraines/Headaches

Hormone-related problems

Head injuries

Loss of consciousness/dizzy

Heart Issues

Seizures

Kidney-related Issues

Chronic Ear Infection

Allergies

Diabetes

Asthma

HIV/AIDS

Cancer

Hospitalizations

Surgeries

Does your child have any other medical conditions? { } Yes { } No If yes, please describe: ____________________________________________________________________

Does your child frequently complain of bodily aches and pains? { } Yes { } No If yes, please describe: _____________________________________________________________________

Does your child miss school because of his/her physical complaints? { } Yes { } No If yes, please describe: _____________________________________________________________________

Does your child have any allergies to medications, drugs or foods? { } Yes { } No If yes, please describe: _____________________________________________________________________

Is your child currently taking any medications?❏ Yes, if yes, include the following information: Name of medications Dosage Prescribed by whom

Name of medication Dosage Prescribing physician

Goals for your child in counseling: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Section 6: Insurance Information Primary coverage:

Patient name:

Policyholder:

Policy ID number:

Group number:

Insurance provider number:

Insurance Company Name:Address:Phone Number:

Secondary coverage, if applicable:

Patient name:

Policyholder:

Policy ID number:

Group number:

Insurance provider number:

Insurance Company Name:Address:Phone Number:

I hereby acknowledge that the information provided above is accurate and current:

Signature___________________________________ Date:____________

Patient Name________________________________________________ Date:_______________

Notice of Policies and Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AN DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Introduction: This notice describes how Red Door Pediatric Therapy handles information about you—how information is used in the office, how information might be shared with other professionals and organizations, and how that information can be accessed. It is important to understand these policies so that the best decisions for you and your family can be made about personal and medical health information. It is a requirement to provide this information to you as a result of privacy regulations of a federal law and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Each time there is a visit by any healthcare provider, information is collected about your physical and mental health. The information is called, according to HIPAA, Protected Health Information (PHI). This information goes into a healthcare record within our office. This information is likely to include the following:

● Past history: childhood, school, work and marital history ● Reason for seeking treatment ● Diagnosis/diagnoses ● Progress notes ● Records from other practitioners treating your child● Legal matters ● Insurance and billing information

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

● “PHI” refers to information in your health record that could identify you. ● “Treatment, Payment and Health Care Operations” (TPO)

○ Treatment is when we provide, coordinate or manage health care and other services related to your health care. An example of treatment would be consulting with another health care provider, such as family physician or another therapist.

○ Payment is obtained reimbursement for your health care. We may disclose PHI to the health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

○ Health Care Operations are activities that relate to the performance and operation of this practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

● “Use” applies only to activities within the office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

● “Disclosure” applies to activities outside of this office such as releasing, transferring, or providing access to information about you to others.

● “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.

II. Other Uses and Disclosures Requiring Authorization

We may use or disclose PHI for other purposes than treatment, payment, or health care operations(TPO) when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. You may revoke all such authorizations (of PHI) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures Not Requiring Consent or Authorization We may use or disclose PHI without your consent or authorization in the following circumstances:

● Child Abuse – If I have reasonable cause to suspect or believe that any child under the age of eighteen years (1) has been abused or neglected, (2) has had non-accidental physical injury, or injury which isn’t consistent with the history given of the injury, or (3) is placed at imminent risk of serious harm, then we are required by law to report this suspicion or belief to the appropriate authority.

● Adult and Domestic Abuse – If we know or in good faith suspect that an elderly individual or an individual, who is disabled or incompetent, has been abused, we may disclose the appropriate information as permitted by law.

● Health Oversight Activities – If a professional oversight organization is investigating this practice, they may subpoena records relevant to such investigation.

● Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records, this information is privileged under state law, and we will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

● Serious Threat to Health or Safety – If we believe in good faith that there is risk of imminent personal injury to you or to other individuals or risk of imminent injury to the property of other individuals, we may disclose the appropriate information as permitted by law.

● Worker’s Compensation – We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s 4 of 5 compensation or other similar programs, established by law, that provide benefits for work related injuries or illness without regard to fault.

IV. Client’s Rights and Therapist’s Duties: Patient Rights

● Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.

● Right to Receive Confidential Communications by Alternative Means and at Alternative Location – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are attending this clinic. On your request, we will send your bills to another address.)

● Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in our health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.

● Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

● Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, we will discuss with you the details of the accounting process.

● Right to a Paper Copy – You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.

● Therapist’s Duties: We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI 5 of 5.

● We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.

● If we revise our policies and procedures, we will notify you by U.S. mail or in person during our session. When information is disclosed, we will disclose the minimum amount of information necessary to address the reason the information was requested.

V. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Heather Arnt or Kelli Ellenbaum. They can be reached at 701-222-3175. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The Privacy Officer can provide you with the appropriate address upon request.

VI. Effective Date

This notice will go into effect on September 15, 2009.

Summary Notice of HIPAA Privacy PracticesWe may share your health information to: treat you, get paid, run the clinic, tell you about other health benefits/services, raise funds, tell family and friends about you, do research, health and safety reasons, military purposes, workman’s comp requests, lawsuits, law enforcement, national security reasons, coroner, medical examiner or funeral director use.

YOU HAVE THE RIGHT TO: get a copy of your medical record, change your medical record if you think it is wrong, get a list of whom we share your health information with, ask us to limit the information we share, ask for a copy of our privacy notice, and complain in writing to the clinic if you believe your privacy rights have been violated.

INDIVIDUAL AUTHORIZATION FOR USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your written authorization before we may use or disclose your protected health information for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information may be used or disclosed. Please read the information below carefully before signing this form.

Signature: ____________________________________________Date:_______________________

Parent/Guardian/Legal representative of Patient:

_____________________________________________________Date:_______________________