Child & Adolescent Intake

Child And Adolescent Patient Questionnaire
Name of Child: (First, Middle, and Last)*
Street Address*
City*
State/Zip*
Phone #*
Social Security #*
Date of Birth*

MonthDayYear
Date
Place of birth
Religion
National Heritage
Height
Weight
Eye Color
Hair Color
Who has legal custody or guardianship of child?*
Who is the Insurance carrier*
Who is the subscriber on the insurance*
What is the member ID on insurance*
What is the group number (if applicable) *
If applicable, who is the secondary insurance carrier
What is the member ID for the secondary insurance carrier
What is the group number for the secondary insurance
Who referred your child?*
What was their concern?*
What is your primary concern?*
What is the school's primary concern?
When did you first become aware of concerns?*
FAMILY DATA
Father:
Name*
DOB
Address
Home Phone*
Work Phone
Place of Employment
Title
Highest Level of Education
Religious Affiliation
Mother:
Name*
DOB
Address
Home Phone*
Work Phone
Place of Employment
Title
Highest Level of Education
Religious Affiliation
Stepmother:
Name
DOB
State/Zip
Social Security #
Place of Birth
Address
Home Phone
Work Phone
Employment
Title
Highest Level of Education
Religious Affiliation
Stepfather:
Name
DOB
Address
Home Phone
Work Phone
Place of Employment
Title
Highest Level of Education
Religious Affiliation
Please identify marital status including dates of all marriages, divorces and remarriages, for both natural and stepparents.
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.

Type a question

	Name	Relationship to your child	Sex	DOB	Education and/or Occupation
Applicant
Stepbrother
Stepsister
Half-brother
Half- sister
Sister
Brother
Miscarriages
Stillbirths

List other children or adults who have lived or are now living in the home and their relationship to the applicant.*
List dates of moves and for what reasons.
How long at present address?*
DEVELOPMENTAL INFORMATION
Length of Pregnancy
Birth Weight
Planned or unplanned pregnancy
Was the pregnancy complicated or involved with drugs or alcohol?
Nature of Delivery

NaturalCaesarianBreech
Condition of child at time of birth:
If the child was adopted, from where?
At what age was the child adopted?
Age of parent at time of birth: Father
Age of parent at time of birth: Mother
Age your child crawled:
Age your child walked:
Age your child talked:
Age your child toilet trained:
What have the significant stressors or traumas been to the family and child? *
EDUCATION HISTORY
Where is child attending school now?*
What grade?*
If it is an ungraded class, state approximate grade achieved:
If child is not enrolled, name last school attended, grade achieved, date withdrawn.

List in order of attendance, all school enrollments child has had; also names of tutors, if any. Give name and address. Indicate if it was a public or private school and the grade attended.

	School	Address	Public or private	Average grade made
#1
#2
#3
#4
#5

Have any grades been repeated? *
Has the child been identified for special education, learning support, or emotional support? Please state year identification and provisions made. *
Please check those items that pertain to your child:

Often fails to finish things he or she startsEasily distractedHas difficulty concentratingShifts excessively from one activity to anotherFrequently is disruptive in classHas difficulty awaiting his/her turn (i.e. games)Has difficulty sitting still.Impulsive or acts without thinkingAbusive to animalsPhysically violent towards property (i.e. vandalism, destructive)Physically abusive to self (scratches self, suicidal attempts)FiresettingStealing, Shoplifting, Breaking and EnteringRunawayLyingChronic violation of parental limitsNicotine Use (what kind?)Drug Abuse (what kind?)Alcohol Abuse (what kind?)Any involvement in juvenile court?Unrealistic fearsActs too young for his/her ageClings to adults or too dependentFeels no one loves him/herGets teased a lotComplains of lonelinessDemands a lot of attentionEasily made jealousRefusal to attend schoolAvoidance of being left aloneExcessive need for reassuranceVery self-conscious or easily embarrassedOften appears tense and un able to relaxFrequent physical complaints (i.e. headaches, stomach aches, nausea)Overly concerned with future eventsNervous mannerisms (i.e nail biting, thumb sucking, rocking)Feelings of inadequacyPanic - feelings of intense fear/discomfort with palpitations, tremors, shortness of breath, chocking feelings, etc.Obsessions - unwanted ideas, images or impulses that intrude on thinking against your wishes and efforts to resist them. (Fear of contamination, recurring doubts about danger, extreme concern with order symmetry or exactness).Can't get his/her mind off certain thingsFears he/she has to be perfectStrange thoughts or ideasHallucinations - visual or auditoryInappropriate expression of feelings (i.e. laughing at something sad)Concern that people are out to get him/herSevere mood changes (i.e. very sad to very happy)Often appears sadConfused or appears to be in a fogDay dreams or appears to be lost in his/her thoughtsDoesn't seem to have much energySocially withdrawnOvertiredPessimistic outlook toward the futureExcessive tearfulness or cryingRecurrent thoughts about death or preoccupation with deathSuicidal thoughts or verbalized intentionsConcerns about sexual identitySexually promiscuousInappropriate sexual behaviorPoor relationship with parentsSibling rivalryNegative peer associates - hangs with others that get in troubleArgues a lot, bragging, boastingMean to othersHas difficulty making or keeping friendsDoes not associate with people hie or her own ageAvoids unfamiliar social situationsIs easily led by othersHas difficulty participating in organized activities (sports)Avoids competitive situationsSleep difficulties (i.e. sleepwalking, restless, inability to fall asleep or sleep too much)Eating difficulties (i.e. has difficulty keeping food down, overeats, does not have much of an appetite, fear of trying new foods, tremendous concern about weight).Poor personal hygiene (does not keep self clean or take an interest in appearance)Enuretic (urinates during the day or at night on self)Encopretic (soils self)Deliberately harms selfTics (sudden rapid, recurrent motor movements or vocalizations)Behaves like the opposite sex
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.
Family Physician*
Orthodontist
Dentist
Psychiatrist/Psychologist/or Mental Health Facility
Medications your child has been on in the past for mood or behavior:*
What medication(s) is your child taking now?*
List any allergic reactions to medications:
List any allergies that your child may have and how it is treated.
If your child has ever been hospitalized please explain when and for what reason. *
Has this child ever been exposed to abuse? Please state whether it is/was physical, emotional or sexual and whether he/she was the object to the abuse or exposed to it.*
Please indicate if any of the following pertain to your child and explain.
Heart Disease
Nausea or vomiting
Concussions
Jaundice
Asthma
Urinary problems
Orthodontia
Visual problems
Injuries or broken bones
Speech problems
Lung Disease
Drug or alcohol abuse
Nervous disorders
Seizures
Dietary problems
Diabetes
Skin Disease
Bowel or elimination problems
Accident prone
Liver Disease
Diarrhea (frequently)
Neurological testing
Fainting
Hearing problems
Tonsillectomy
Irregular Sleep Patterns
High Fevers
Activity limitations
Gynecology

Please fill out if over the age of 12
Sexually active? (if so, please describe history of sexual behavior)
Pregnancy

YesNo
Abortion (If so, when?)
Miscarriage (If so, when?)
Menstrual Problems
Birth Control (If so, what type?)
FAMILY MEDICAL/PSYCHIATRIC HISTORY

Please check which, if any, of the following conditions/problems apply to your child's blood relatives. If other significant medical/psychiatric problems are present among blood relatives, please list those in the space provided below.

	Child's Mother	Child's Father	Child's Brother(s)	Child's Sister(s)	Child's Grandparent(s)	Other
Childhood oppositional/defiant
Problems with aggression
Attention problems
Learning disability
Failed high school
Mental retardation
Psychosis/schizophrenia
Depression (greater than 2 weeks)
Anxiety or adjustment disorder
Panic disorder
Other mental disorder
Tic disorder or Tourette's
Alcohol Abuse
Substance Abuse
Antisocial behavior (assault/theft)
Arrests/incarcerations
Physical Abuse (victim)
Physical Abuse (perpetrator)
Sexual Abuse (victim)
Sexual Abuse (perpetrator)

Name of person completing this form:*
Relationship to applicant:*
I do verify that all the foregoing information is true and complete. (Fill in name below)*
DATE*

MonthDayYear
Date
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.
What day of the week works best for your appointments
What time of day works best for your appointments
I, name* , have read, understand, and agree to the terms outlined in this agreement.
Client Signature *

Clear
Client Signature Date *

MonthDayYear
Date
Clinician Signature

Clear
Clinician Signature Date

MonthDayYear
Date
Standard Authorization for Disclosure of Mental Health / Substance Use Treatment Information
I,Type a label, born onblanks authorize Deaton & Deaton Counseling & Consulting, LLC to disclose to and/or obtain fromblank the following information:
Description of Information to be Disclosed

AssessmentDiagnosisPsychosocial EvaluationPsychological EvaluationPsychiatric EvaluationTreatment Plan or SummaryCurrent Treatment UpdateMedication Management InformationPresence/Participation in TreatmentDrug Screen Results/All LabsNursing/Medical InformationOther
Purpose

Educational InformationDischarge/Transfer SummaryContinuing Care PlanProgress in TreatmentDemographic InformationPsychotherapy Notes (cannot be combined with any other discloser)Other
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: blanks
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: blanks Or, as otherwise indicated: blank
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.
Signature of Patient/Client

Clear
Date Signed

MonthDayYear
Date
Signature of Parent, Guardian or Personal Representative (Please specify your role as the Personal Rep

Clear
Date Signed

MonthDayYear
Date
Personal Rep Capacity for Authorization:
Check here is patient/client refuses to sign authorization
Signature of Staff Witness

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Child And Adolescent Patient Questionnaire

FAMILY DATA

Father:

Mother:

Stepmother:

Stepfather:

DEVELOPMENTAL INFORMATION

EDUCATION HISTORY

PSYCHIATRIC/PSYCHOLOGICAL/MEDICAL

Gynecology

FAMILY MEDICAL/PSYCHIATRIC HISTORY

CLIENT/PSYCHOLOGIST SERVICE AGREEMENT

PSYCHOLOGICAL SERVICES

APPOINTMENTS

PROFESSIONAL FEES

PROFESSIONAL RECORDS

CONFIDENTIALITY

CONSULTATIONS

PARENTS & MINORS

CONTACTING ME

ADDITIONAL RIGHTS

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