Child Intake (online) – The Psychology Clinic

Child's Name: *

First

Last

Date of Birth: *

Age

Selected Value: 0

Gender *

Custody of Child (e.g., physical and/or legal): *

Primary Care Physician:

Address *

Address Line 1

Address Line 2

City

State

Zip Code

School: *

Grade:

Selected Value: 0

Teacher e-mail:

Father's Name: *

Date of Birth: *

Spouse’s name: *

Employer: *

Phone: *

May a message by left on: *

Home Phone
Cell
Work
None

Father's email: *

Mother's Name: *

Date of Birth: *

Spouse’s name: *

Employer: *

Phone: *

A message may be left on: *

Home Phone
Cell
Work
None

Mother's email: *

Reason for referral: *

How did you hear about us? *

Were there any complications with the pregnancy, labor, or delivery? Please explain. *

Was the child exposed to any drugs, alcohol, or prescription medicines during his/her mother's pregnancy? *

Gestational Age: *

Birth Weight: *

At what age were motor milestones (sitting, standing, walking) and speech/language milestones (first words, two word phrases, sentences) met? *

Who lives in the home with your child? *

Describe the parenting style(s) within the home: *

Sleeping habits: *

Eating habits: *

Does the child have an IEP (Individualized Education Plan) in school? If yes, please indicate the eligibility and modifications received. *

Has the child experienced any abuse or neglect? *

Describe the parent/child relationship. *

Relationship with father: *

Good
Average
Poor
n/a

Relationship with mother: *

Good
Average
Poor
n/a

Relationship with stepfather: *

Good
Average
Poor
n/a

Relationship with stepmother: *

Good
Average
Poor
n/a

Relationship with sibling 1: *

Good
Average
Poor
n/a

Relationship with sibling 2: *

Good
Average
Poor
n/a

Relationship with sibling 3 *

Good
Average
Poor
n/a

Describe your child’s relationship with adults and peers. *

Describe any past/current family stressors or traumatic events. *

Does the child have any current medical/mental health diagnosis(es)? Please explain. *

If you answered yes to the above question, please list any current therapy, ongoing evaluations, and medications (prescribing physician)? Include over-the-counter medications.

Any past therapy, evaluations, and mediations (prescribing physician), or mental/medical health diagnosis(es)? *

Describe any family mental health problem. *

Describe the child's history/current use of drugs or alcohol. *

Please provide any additional information that you would like to share.

To which cultural group does your child belong? *

Please describe your child's social support network. *

Do we have permission to communicate with the person/organization referring you/your child to this office? *

Yes
No

Electronic Signature *

Date *

Name of Primary Insurance: *

Policyholder's Full Name: *

Policyholder's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Policyholder's Date of Birth: *

Policyholder's Social Security Number: *

Policyholder's Employer: *

Policyholder's ID Number: *

Group Number:

Insurance Telephone Number: *

Client's or authorized signature. I authorize both the release of any medical information necessary to process my claim and authorized payment or medical benefits to The Psychology Clinic and the providing therapist. *

Date: *

Do you have a secondary insurance? *

Yes
No

Name of Secondary Insurance:

Policyholder's Full Name:

Policyholder's Address

Address Line 1

Address Line 2

City

State

Zip Code

Policyholder's Date of Birth:

Policyholder's Social Security Number:

Policyholder's Employer:

Policyholder's Secondary Insurance ID Number:

Policyholder's Secondary Insurance Group Number:

Secondary Insurance Telephone Number:

Client's or authorized signature. I authorize both the release of any medical information necessary to process my claim and authorized payment or medical benefits to The Psychology Clinic and the providing therapist.

Date:

Policies & Procedures (Signature Required) *

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT: This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. The Georgia Notice, which is attached to this agreement, explains HIPPA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information at the end of this session. CONFIDENTIALITY All communications between client and therapist will be held in confidence, and will not be revealed to anyone unless you (or parent, in the case of a minor) give written authorization to release this information. Your legal right to privileged communication between a licensed psychologist and a client will be upheld unless overruled in a court of law during a legal proceeding. Georgia law requires that confidentiality be waived when the client’s or other’s personal safety is threatened or when disclosure of child abuse is made to the therapist. If we determine that a client presents a serious danger of violence to another, we may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the client. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary.

Minors & Parents (Signature required) *

MINORS AND PARENTS: Unemancipated clients under 18 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records unless we believe that doing so would endanger the child or be countertherapeutic. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, we will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any of his/her objections. FINANCIAL ARRANGEMENTS AND INSURANCE Initial consultation, 45-55 minute individual and/or family sessions, and psychological assessments and interpretations are billed at $200.00 per clinical hour. It is your responsibility to pay your bill. Our office will be glad to file your primary and secondary insurance for you (please provide our office with a copy of your insurance card). We cannot file tertiary insurance. If your insurance company is unwilling to pay, it is your responsibility to make payment and contact the insurance company.

Late Cancellation/Missed Appointment Policy (Signature required) *PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING.* *

The Psychology Clinic, effective January 1, 2021, will begin collecting a $75.00 refundable deposit (unless contractually prohibited by insurance/provider) prior to scheduling initial intakes. This practice helps offset losses due to no-shows or late cancellations not covered by insurance. If someone cancels late or misses an appointment, we incur a loss of income for that hour and are not able to offer that time to someone who may be waiting, possibly in crisis. Typically, the credit card information is taken ahead of time due to the difficulty of calling and charging a client the cancellation fee once they have missed the appointment. Many people will not answer the phone or willingly hand over their credit card information. Deposits are returned at the conclusion of therapy for those having attended scheduled appointments and without no shows and late cancellations. The initial $75 deposit covers only the first no show or missed appointment; another deposit is required to cover an upcoming appointment(s). We reserve a therapeutic hour for each person(s) scheduling an appointment; and our income is based entirely on the hours we see clients. Therefore, we must have an agreement that the appointment will be kept or, if you must cancel, we need to have ample notice to prevent this type of loss. Regardless of cause, The Psychology Clinic requires a 48-hour notice on cancellation to release you from your responsibility for that time scheduled. I agree to the terms of the late cancellation/missed appointment policy of The Psychology Clinic and will make prompt payment on any charge I incur for a late cancellation or missed appointment. I understand the therapeutic and economic necessity of such a policy.

___FCR Collection Services Authorization & Prior Consent to Current Service Agreements/Contracts__ (Signature required) *

I understand that if I have an unpaid balance to The Psychology Clinic and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of any fees from the collection agency, including all costs and expenses incurred collecting my account, and possibly including reasonable attorney's fees if so incurred during collection efforts. In order for The Psychology Clinic or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that The Psychology Clinic and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable.