Child and Adolescent Intake Form - The Psychology Clinic

Step 1 of 5

Child's Name

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

School

Grade

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

Father/Guardian

Date of Birth

Employer

Phone

Mother/Guardian

Date of Birth

Employer

Phone

Primary Care Physician

I hereby give my permission for my child to receive services.

Date

POLICIES & PROCEDURES (Please sign below)

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 required 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 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 CANCELLATIONS/MISSED APPOINTMENTS We reserve a therapeutic hour for each person(s) scheduling an appointment; and our income is based entirely on the hours we see clients. 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. 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. You will be billed for late cancellation and/or missed appointments at a rate of $75.00 per clinical hour. Please note that insurance companies do not reimburse for canceled or missed sessions. I/we agree to the above terms of the late cancellation/missed appointment policy of The Psychology Clinic and will make prompt payment on any charge I/we incur for a late cancellation or missed appointment. I understand the therapeutic and economic necessity of such a policy. Your signature below indicates that you have read and understand the policies and procedures described above.