Child MH Packet

Evergreen Youth & Family Services

Child Mental Health Packet
Evergreen Youth & Family Services is passionate and cares about youth mental health. A referral has been made to our office due to concerns about your child. Counseling services are free and available to help youth issues in relation to communication, anger management, youth behavior concerns, family conflict resolution, juvenile justice involvement, and unresolved grief and loss. Evergreen Youth & Family Services provides private, confidential, evidence-based counseling for children, teens and their families. Our goal is to help youth overcome their difficulties and become more resilient.

A problem and goal-specific individual treatment plan will be developed between the therapist and client. The treatment plan will be reviewed with the client and updated every 90 days. The potential benefits of receiving mental health and therapy services include the possibility that an individual will experience symptoms relief, improved self-knowledge, and improved personal functioning in important life areas.

In order to provide services to a minor a signature from a parent/legal guardian is required on a consent to treat form and authorization of information of information in order to see child. Once the forms are signed a therapist can begin services. Thanks for your time and cooperation in advance.

Please note that the Signature for Mental Health Treatment is effective for one year from the date of signing.

Consent for Treatment & Authorization Form

Evergreen staff looks forward to helping you reach your goals. This form requests information to better serve you. All information between provider and patient is held strictly confidential unless you authorize release of confidential information; you present physical danger to yourself or other(s); or child/elder abuse or neglect is suspected. I am required by law to inform potential victims and legal authorities so that protective measures can be taken.

I.         Receipt of Required Notices: I hereby acknowledge that I have received a copy of Evergreen Youth & Family Services’ (EYS) Notice of Privacy Practices and a copy of your Additional Rights (Equal Access, Quality Treatment and Privacy, etc.).

II.       Consent for treatment and use of personal health information (PHI): I acknowledge that I have consented to receive mental health and related services from the staff of EYS which will be described in full in the treatment planning process. I understand that I must consent to receive services or I will not be served. I further acknowledge that I consent that my PHI, including information regarding chemical dependency, may be used for treatment, payment, or service referrals, subject to the uses and limitations set forth in state and federal law. Any additional uses of my PHI beyond those which are provided for in state and federal law shall require my authorization.

In some instances, counseling services may be covered by grant sources but if you do have insurance, we are required to use that source first and request that you please present that information. If applicable, upon verification of health plan/insurance coverage and policy limits, your insurance carrier will be billed for you and EYS will be paid directly by the carrier.   Please note that Evergreen has a policy that we will cover costs not paid by insurance companies for mental health services.
I, *
enter parent/guardian name
authorize the release of information regarding my care to my health plan for the payment of claims, certifications/ case management decisions, and other purposes related to the administration of benefits for my health plan.

I further authorize and request that my treating provider carry out mental health examinations, treatments, and/or diagnostic procedures, which now or during the course of my care are advisable. I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable.

I understand and agree to all of the above information.
Client Name

First Name Last Name
Client Signature

Clear
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Signature *

Clear

SCHOOL/WORK
Grade
Current School
Class Placement

Mainstream Special Class
If special class, where?
Is there an IEP in place?

Yes No
Does the child have any learning disabilities?

Yes No
If yes, please describe

LEGAL
Is the child currently on probation?

Yes No
Probation Officer
Are there any current or pending legal actions against the child?

Yes No
If yes, please explain

INSURANCE INFORMATION

Please indicate how the services requested are to be paid?
Bill insurance carrier or other as indicated.

Insurance (primary) Insurance (secondary) Medical Assistance Grant Funded (CVS/YIP)
Primary Insurance Carrier
Other Pay Source
Primary Insurance Group #
Primary Insurance Policy #
Amount Covered
Secondary Insurance Carrier
Client Co-Pay (if applicable)
Secondary Insurance Group #
Secondary Insurance Policy #
Amount Covered
Medical Assistance #
FOR GRANT FUNDED PURPOSES. Do any of the following apply to you: Juvenile involvement such as misdemeanor, felony, probation history, juvenile detention center, chemical dependency center, court-ordered for mental health treatment, etc.

Yes No
Should be Empty:

	Yes	No
Planned?
Welcomed?
Stressful?

Evergreen Youth & Family Services