• Child And Adolescent Patient Questionnaire

    Child And Adolescent Patient Questionnaire

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  • FAMILY DATA

  • Father:

  • Mother:

  • Stepmother:

  • Stepfather:

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  • List on this page in chronological order the names of all children including the applicant, stepbrothers and sisters, half brothers and sisters, and any miscarriages or stillbirths. Also give a brief description of each child. (Birth date, school status, significant characteristics Please state their relationship to applicant.

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  • DEVELOPMENTAL INFORMATION

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  • EDUCATION HISTORY

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  • PSYCHIATRIC/PSYCHOLOGICAL/MEDICAL

  • List all doctors and mental health professionals who have examined and/or treated your child. Please give name, address and phone number for each.

  • Please indicate if any of the following pertain to your child and explain.

  • Gynecology

    Please fill out if over the age of 12
  • FAMILY MEDICAL/PSYCHIATRIC HISTORY

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  • CLIENT/PSYCHOLOGIST SERVICE AGREEMENT

    Informed Consent
  • Welcome to Deaton and Deaton Counseling! The following is a document outlining our services and policies. Though long and often complex, it is important you understand them fully as they represent an agreement between yourself and Deaton and Deaton. All questions and/or concerns will be addressed upon the completion of these documents, as well at any time in the future.

  • PSYCHOLOGICAL SERVICES

  • Psychotherapy consists of a relationship between two individuals in which each individual has a set of clearly defined rights and responsibilities. As a client in psychotherapy, it is important you understand your rights, the legal limitations to those rights, your responsibilities as a client, and my corresponding responsibilities as your therapist. All rights and responsibilities are explained in the following sections.

    There are both benefits and risks to psychotherapy; risks which may include experiencing feelings of discomfort, such as anxiety, fear, frustration and helplessness to name a few. The process of psychotherapy often requires the discussion of unpleasant aspects of your life, however, it often leads to a significant reduction in feelings of distress. It has also been shown to help increase satisfaction in interpersonal relationships, one’s personal awareness and insight, as well as stress management and problem-solving skills. Therapy requires active effort on your part, which may include your working on things we have discussed outside of the sessions. Remember, there are no guarantees in therapy.

    The first two to four sessions will involve a comprehensive evaluation of your needs, at the end of which initial impressions of what our treatment plan may include. Treatment goals will be discussed, and an initial treatment plan will be created; be sure to evaluate and assess your comfort level with both the treatment plan and myself as your therapist. Any questions about my procedures should be addresses whenever they arise; should any doubt(s) persist, I will be happy to help you find and schedule an appointment with another mental health professional for a second opinion.

  • APPOINTMENTS

  • Appointments will range from 45 to 60 minutes in duration, once per week at a time we both agree on; that time is reserved for you and you alone. If you need to reschedule or cancel a session, 24 hours’ notice is required; sessions canceled within 24 hours of your appointment time, as well as missed sessions without notice, are subject to billing for the agreed upon session amount. You are required to be on time for your sessions, otherwise you forfeit that time and the session will still need to end on time. Frequency of sessions are adjusted as needed.

  • PROFESSIONAL FEES

  • The agreed upon fee for your session(s) is $90, due at the time of your session unless otherwise specified. Sliding fee scale is avaliable on request. Acceptable payment methods include cash, check or credit card; returned checks are subject to an additional $50.00 fee, and payment by check will no longer be an option. I reserve the right to utilize an attorney of collection agency to secure payment should you refuse to pay debts owed by you to Deaton and Deaton Counseling and Consulting, LLC.

  • PROFESSIONAL RECORDS

  • It is required that I keep records of the psychological services provided; brief records noting you were here, your reasons for seeking therapy, treatment goals and progress, diagnoses, topics of discussion, medical/social/treatment histories, records received from other providers, copies of records sent to others, as well as your billing records. You have a right to receive a copy of your records except in unusual circumstances, such as those involving danger to yourself or others. Remember, these are professional records and may be misinterpreted and/or upsetting to untrained readers; it is recommended initial reading of case files be done with myself or another mental health care provider. You have the right to request, in writing, that a copy of your file be made available to any other health care provider. Should any request for access be denied, you reserve the right to have my decision reviewed another mental health professional. All client records will be kept in a secure location in the office.

  • CONFIDENTIALITY

  • The privacy of all communications between a patient and a therapist is protected by law and may only be released with your written permission, with the following exceptions:

    1)      In legal proceedings a judge may order my testimony or request your records if he/she determines that the issues demand it.

    2)     If I believe that a child, elderly person, or disabled person is being abused, I must file a report with the appropriate state agency.

    3)     If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.

    4)     If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

    These situations have rarely occurred in my practice, however, should one occur I will attempt to both make you aware and discuss fully the circumstances before taking any action.

  • CONSULTATIONS

  • I have often found it helpful to consult my clinical supervisor or other mental healthcare professionals about a case, during which confidentiality of my clients is maintained fully; consultants are also legally bound to maintain confidentiality. While this summary may prove helpful in informing you of confidentiality standards and its limitations, it is important we discuss and questions or concerns you may have as soon as they arise.

  • PARENTS & MINORS

  • Privacy in therapy is crucial, however, parental involvement can be essential in treatment progression. It is my policy not to provide treatment to a child/adolescent under the age of 12 years of age unless s/he agrees that I be able to share whatever information I consider necessary with the parent. When treating adolescents age 13-17, it is requested that an agreement between myself, the client and the parents be made allowing me to share general information about treatment progress, attendance and a summary of treatment upon completion. Any other form of communication will require client agreement, unless there is a threat to the safety and wellbeing of the client/others (see above section on Confidentiality); in which case every effort will be made to inform and discuss with the client my intentions and address any concerns or objections they may have.

  • CONTACTING ME

  • I am often not available immediately, in which case, you may leave a message on my confidential voice mail/e-mail and I will get back to you as soon as possible. Correspondences will be addressed in the order of urgency, meaning it may take a day or two for me to respond. If you do not hear from me, or if I am unable to reach you, and you feel as if you cannot wait or keep yourself safe:

    1)     Contact your Primary Care Physician

    2)    Go to you local Emergency Room & request to see the Mental Health Professional on staff

    3)    Call 911 and ask to speak with the Mental Health Professional on call

    Every attempt will be made by myself to keep you informed of any planned absences and provide you with the name and contact information of the mental health professional covering my practice.

  • ADDITIONAL RIGHTS

  • You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy, my specific training and experience, as well as expect that I will not have social or sexual relationships with clients or with former clients. If you find you are dissatisfied with the treatment you are receiving, please make me aware so that I may respond and adapt as your concerns arise. Such concerns will be taken seriously and handled with care and respect. It is within you rights to request a referral to another therapist and/or end therapy as any time.

  • I, * , have read, understand, and agree to the terms outlined in this agreement.

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  • Standard Authorization for Disclosure of Mental Health / Substance Use Treatment Information

  • I,, born on authorize Deaton & Deaton Counseling & Consulting, LLC to disclose to and/or obtain from the following information:



  • This information may be used or disclosed in connection with mental health/substance use treatment, payment, or healthcare operations. If the purpose is other than as specified above, please specify:

  • Revocation 

    I understand that I have a right to revoke this authorization at any time by sending written notification to Deaton & and Deaton Counseling & Consulting, LLC, at 1100 US 127 S Suite C4, Frankfort, KY 40601. I further understand that a revocation of the authorization is not effective to the extent that extent that action has been taken in reliance on the authorization.

  • Expiration

  • Unless sooner revoked, this authorization expires on the following date: Or, as otherwise indicated:

  • Conditions 

    I further understand that Deaton & Deaton Counseling & Consulting, LLC will not condition my treatment condition my treatment on whether I give authorization for the requested disclosure. 

    Form of Disclosure 

    Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve
    the right to disclose information as permitted by this authorization in any manner that we deem to be
    appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or
    electronically.

    Redisclosure

    I understand that there is the potential that the protected health information that is disclosed pursuant to this
    authorization may be redisclosed by the recipient and the protected health information will no longer be
    protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and
    provides additional privacy protections.

    I will be given a copy of this authorization for my records.

     

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