Intake Form for New Child Clients

Thank you for choosing Integrative Counseling Solutions, Inc. for your health care needs. Please be sure to have essential information such as insurance info, medications, etc. on hand in order to complete these forms successfully.

If your child is receiving services in the school, we require one family session per month with a parent or guardian. This policy has been put in place to best meet the needs of our clients, help the therapist understand what is going on at home and help the parents/guardian understand what the therapist is working on with the child.

School Consent and School Release of Information forms also MUST be signed and returned with a credit/debit form to be kept on file for co-pays, missed appointments or canceled insurance.

If you need help at any time call us Mon-Fri., 9am-5pm at (515) 267-1340.

I hereby give consent for my child to receive therapy and/or skill development services by Integrative Counseling Solutions, Inc. I understand that their insurance will be notified of my consent for them to receive services and that information will be shared with their insurance company for the purpose of payment.

I understand that if the parent/guardian of the child does not sign this agreement, a Court Order must be attached to this form indicating who has legal authorization to grant permission to treat.

Child's Full Legal Name

Parent/Guardian Signature *

Clear

Date: *

Date

If required, upload Court Orders and relevant documentation here:

Health care services are available by two-way interactive video communications and by the electronic transmission of information. Referred to as “telemedicine”, this means that I/my child may be evaluated and treated by a health care provider from a different location. Since this is different than the type of consultation with which I am familiar, if I choose to have my child participate in this type of service, I understand and agree to the following:

1. The health care provider will be at a different location from me/my child.

2. I will be informed if any additional personnel are to be present other than myself and any individuals accompanying me. I will give my verbal permission prior to additional personnel being present.

3. Video recordings may be taken of the telemedicine consultation after I have given my written permission prior to recording. Video recording and other data including images and photos may be kept, viewed, and used for purposes including teaching, training, technically, scientific, research, or administrative purposes.

Noting all the above, I understand that my/my child's participation in the process described (called “telemedicine”) is voluntary and constitutes a waiver of the usual right to patient privacy and may possibly increase the risk of disclosure of my/my child's medical or mental health data.

I further understand that I have the right to:

1.Refuse the telemedicine consultation or stop participation in the telemedicine consultation at any time.

2.Request that the health care provider refrains from transmitting my/my child's information if I make the request before the information is transmitted.

3.Request that nonmedical personnel leave the room at any time.

I acknowledge that the health care provider involved explained the consultation in a satisfactory manner and that all questions that I have asked about the consultation have been answered in a manner satisfactory to me or my representative.

Understanding the above, I consent to the telemedicine process described above.

This agreement will remain in effect for one year. Please sign below to agree.

Parent/Guardian Signature *

Clear

Date: *

Date

Witness

If this client has another parent not living in the same home as the parent completing this form, and whose legal parental rights have not been terminated, please provide a name, address and phone number.

Other Parents' Name

First Name Last Name

Other Parents' Phone Number

Please enter a valid phone number.

Other Parents' Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Other Parents' Signature

Clear

Date

Witness (if applicable)

Witness' Relationship to Client

Please only report contact information where we may identify ourselves as Integrative Counseling Solutions, Inc. on the voice mail, email, and/or text message.

Child Client’s Legal Name: *

Child Client’s Preferred Name:

Current Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Date of Birth: *

Date

Social Security Number: *

Gender:

Preferred Pronouns:

Race and/or Ethnicity

Parent/Guardian Phone # 1: *

*

Cell Home Work Other

Parent/Guardian Phone # 2:

Cell Home Work Other

Parent/Guardian Email: *

example@example.com

Parent/Guardian Preferred Methods of Communication (select all that apply) *

Call Text Email Other

Name:

Phone:

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Initial here if you do not wish to list an emergency contact person:

Other Household Members

Name

Relationship

Age

Occupation

Household member #1

Household member #2

Household member #3

Household member #4

Is where you and your child are living safe? *

Yes No Other

Name(s) and your childs' relationship with them

Child's Schools Attended

School Name

City

State

Dates Attended

Last Grade Completed

School #1

School #2

School #3

School #4

CHILD'S OCCUPATIONAL INFORMATION (please check all that apply):

Present Occupation: *

Not Applicable Full Time Part Time Disabled Unemployed/Looking Unemployed/Not Looking Retired Other

Child's Recent Employment (please list current job first):

Employer, City and State

City

State

Dates Worked

Occupation

Most Recent Employer

Next Most Recent Employer

Presenting Issues (please check all that apply):

Further Psychological Issues:

Hallucination Delusions Paranoia Loss of touch with Reality Other

Other Issues You Would Like Us To Know About:

Which of the following has your child used (check all that apply):

Caffeine Alcohol Marijuana Drugs Cigarettes/Tobacco Other

If your child has ever been hospitalized for mental health reasons, please complete the table below. If not, please initial here:

Hospital Name

Date Entered

Date Discharged

City

State

Was It Helpful?

Event #1 (most recent)

Event #2

Event #3

Event #4

It may be necessary to sign a release of information for previous providers in order to request any information they have gathered about your child.

Primary Care Physician (PCP):

Release Signed

Psychiatrist:

Release Signed

List any Allergies or Sensitivities:

List any Physical Injuries

List any Hospitalizations/Surgeries:

Hospital

Procedure

Date

Details (if needed)

Event #1 (most recent)

Event #2

Event #3

List any Disabilities:

List any Diagnosed Diseases:

List of Child's Prescribed Medications:

Medication Name

Prescriber

Dosage

Frequency

Start Date

Med #1

Med #2

Med #3

Med #4

Med #5

List Alternative/Over the Counter Medications:

Medication

Dosage

Frequency

Start Date

Med #1

Med #2

Med #3

Med #4

Med #5

This information is pertinent to the client’s mental health, behavioral or academic needs as deemed by either agency. This information may contain copies of discharge summaries, clinical notes or diagnostic tests pertaining to the client’s evaluation and treatment. This release may be requested for additional purposes or include additional information as specified below:

Collaboration of Treatment Plans & Services Other:

Request Records

The information shared may be written and/or verbal and it may be currently in existence and/or that which is made in the future. This information will only be shared with appropriate personnel on a need to know basis. This authorization is good for one year from the date signed. I understand I may revoke this authorization at any time by giving written notice to Integrative Counseling Solutions. I understand that any release made prior to my revocation in compliance with this authorization shall not constitute a breach of my/my childs' rights to confidentiality.

I understand my healthcare and payment for my/my childs' healthcare will not be affected by this authorization.

I authorize Integrative Counseling Solutions to exchange information with my childs' health care provider(s):

Clear

Child Clients Full Name:

Date of Birth:

Date

Provider Name(s) (MD/ARNP/Other):

Clinic Name(s):

This information is pertinent to the client’s mental health, behavioral or academic needs as deemed by either agency. This information may contain copies of discharge summaries, clinical notes or diagnostic tests pertaining to the client’s evaluation and treatment. This release may be requested for additional purposes or include additional information as specified below:

Collaboration of Treatment Plans and Services

Request Records (please check the circle if applicable to request records)

The information shared may be written and/or verbal and it may be currently in existence and/or that which is made in the future. This information will only be shared with appropriate personnel on a need to know basis. This authorization is good for one year from the date signed. I understand I may revoke this authorization at any time by giving written notice to Integrative Counseling Solutions. I understand that any release made prior to my revocation in compliance with this authorization shall not constitute a breach of my rights to confidentiality. I understand my healthcare and payment for my healthcare will not be affected by this authorization. Specific Authorization for Release of Information Protected by State/Federal Law.Request Records (please check the circle if applicable to request records)

I specifically authorize the release of data and information relating to:

Substance abuse (alcohol/drug use) Mental Health HIV

Signature of Childs' Parent/Guardian

Clear

Printed Name of Child's Parent/Guardian

Date

Signature of Witness (if applicable)

Clear

Witness' Relationship to Client (if applicable)

Printed Name of Witness (if applicable)

PROHIBITION ON REDISCLOSURE

This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (42 C.F.R. Part 2) and state requirements (Iowa Code Ch. 22) prohibits further disclosure without the specific written consent of the client or as otherwise permitted by such law and/or regulations. A general authorization for the release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may attach for unauthorized disclosure of alcohol/drug abuse or mental health information.

* Only persons 18 years of age or his/her legal representative may authorize release of mental health information.

** Only the subject may authorize release of substance abuse information unless the subject is under legal age or incompetent as defined by statute. Sharing information: It is the responsibility of all agencies listed to provide requested information. The recipient of the information is responsible for maintaining confidentiality of the information.

This information is pertinent to the client’s mental health, behavioral or academic needs as deemed by either agency. This information may contain copies of discharge summaries, clinical notes or diagnostic tests pertaining to the client’s evaluation and treatment. This release may be requested for additional purposes or include additional information as specified below:

Collaboration of Treatment Plans and Services

Request Records (please check the circle if applicable to request records)

The information shared may be written and/or verbal and it may be currently in existence and/or that which is made in the future. This information will only be shared with appropriate personnel on a need to know basis. This authorization is good for one year from the date signed. I understand I may revoke this authorization at any time by giving written notice to Integrative Counseling Solutions. I understand that any release made prior to my revocation in compliance with this authorization shall not constitute a breach of my rights to confidentiality. I understand my healthcare and payment for my healthcare will not be affected by this authorization. Specific Authorization for Release of Information Protected by State/Federal Law.Request Records (please check the circle if applicable to request records)

I specifically authorize the release of data and information relating to:

Substance abuse (alcohol/drug use) Mental health HIV Other

Parent/Guardian Signature

Clear

Relationship to Client

Date

Witness (if applicable)

I hereby give consent for my child to receive mental health services, which may include but are not limited to; group counseling, substance abuse and/or skill development or neurofeedback as needed, by Integrative Counseling Solutions, Inc.

If Integrative Counseling Solutions, Inc. has an agreement with my child’s school, I give permission for my child to be seen at the school for mental health services and have signed the attached release of information for information to be exchanged with my child’s school.

I understand and agree with the terms for Integrative Counseling Inc.’s School Based Mental Health Program. I understand the importance of my/our involvement in therapy.

Health care services are available by two-way interactive video communications and by the electronic transmission of information.

Referred to as “telemedicine”, this means that I may be evaluated and treated by a health care provider from a different location.

Since this is different than the type of consultation with which I am familiar, I understand and agree to the following:The School Based Mental Health Program requires a minimum of one family counseling session per month (and more if indicated by the child’s therapist) in order to best meet the needs of our clients, help the therapist understand what is going on at home and help the parents/guardian understand what the therapist is working on with the child.

I understand that a credit or debit card must be on file with Integrative Counseling Solutions, Inc. to cover any deductible or co-pay/co-insurance required by my insurance company unless my child is covered by Medicaid (Title XIX).

I understand that I must advise Integrative Counseling Solutions, Inc. immediately of any changes to my child’s insurance coverage, as all therapists are not on all insurance panels.

If the insurance does change, then a change in therapists may be needed in order to use my child’s insurance.

I understand that if someone other than the parent/guardian of the child signs this agreement, a Court Order must be attached to this form indicating who has legal authorization to grant permission to treat.

This agreement will remain in effect for one year.

Parent/Guardian Signature *

Clear

Date

Other Parent/Guardian Signature (if applicable)

Clear

Witness (If applicable)

THE FOLLOWING NOTICE DESCRIBES HOW YOUR CHILDS' MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY!

Integrative Counseling Solutions, Inc., maintains full compliance with all local, state and federal laws and regulations pertaining to protected health information.

Generally, no protected health information will be disclosed to any third party or agency without your specific, written authorization. There are circumstances, however, where Integrative Counseling Solutions, Inc., may disclose some protected health information about a client without an express, written authorization.

These include disclosures made to secure payment for services rendered, as where your health insurer requests information from our files to process a payment for services, pursuant to their agreement with you.

If, however, you, or any one you authorize, pays the full fee for services of Integrative Counseling Solutions, Inc., without submitting a claim to an insurer or agency for payment, no such disclosure will be made.

Another example is a limited release for purposes of treatment. Integrative Counseling Solutions, Inc., may share certain protected health information with other staff persons, including professional staff, at Integrative Counseling Solutions, Inc., to enable that person to treat a client.

A third situation where a release of protected health information can occur is when necessary for health care operations. An example of this is when certain protected health care information is shared with support staff of Integrative Counseling Solutions, Inc.

All health care providers, including Integrative Counseling Solutions, Inc., are required, under state law, to report to the appropriate government agency, instances where it has a reasonable basis to believe a child or dependent adult has been or is likely to be abused or neglected.

Similarly, if a client threatens self-harm, we may be required to notify law enforcement or family members who can help provide protection.

In addition, if a client communicates a threat or intent to cause significant physical harm to an identifiable person or persons, Integrative Counseling Services, Inc., may be required to disclose protected health information concerning the threat to the affected person or to law enforcement personnel.

This is known as our “duty to warn.” In addition, Integrative Counseling Solutions, Inc., may be required to release certain information by court order or pursuant to a subpoena.

No protected health information will be disclosed for purposes of marketing or fundraising without your prior, written, approval.

Integrative Counseling Solutions, Inc., may contact a client or the guardian or custodial parent of a client to provide appointment reminders or to provide information about treatment alternatives.

You have the right to request certain restrictions on certain uses and disclosures of protected health information, but Integrative Counseling Solutions, Inc., is not required to agree to such restrictions.

The client or, in the case of an unemancipated minor, the guardian or custodial parent of a client, has the right to inspect and copy protected health information about the client, and to amend such information and to receive certain confidential communication from Integrative Counseling Solutions, Inc.

Integrative Counseling Solutions, Inc., is required by law to maintain the privacy of protected health information. It also has the right to change its privacy practices.

Any change in privacy practices will necessitate the client or, in the case of an unemancipated minor, the guardian or custodial parent of a client, to be given a revised Notice of Privacy Policies.

In the event a client, or in the case of an unemancipated minor, the guardian or custodial parent of a client, wishes to make a complaint about a violation of these privacy policies, a complaint may be made to Integrative Counseling Services, Inc., as set out in the Client Handbook, or to the Secretary of the Department of Health and Human Services by going to the website: HHs.gov/ocr/privacy and following the instructions for filing a complaint.

In the event of a breach of the confidentiality requirements set out in local, state or federal laws or regulations, Integrative Counseling Solutions, Inc., may have an obligation to notify the client or, in the case of an unemancipated minor, the guardian or custodial parent of a client of such breach.

It is your responsibility to keep Integrative Counseling Solutions, Inc., advised as to how you wish such a notification to be communicated to you. We ask that you keep your contact information current.

If you wish notification to be made by electronic needs, you should be aware that e-mail, cell phone, text messaging and fax transmissions may not be secure.

Parent/Guardian Signature *

Clear

Printed Name *

Date *

Date

Witness (if applicable)

Please include ALL relevant insurance sources for the new/returning patient.

Primary Insurance

Secondary Insurance

Additional Insurance #1

Additional Insurance #2

Insurance Company Name

Subscriber (name on card)

Subscriber Date of Birth

Healthcare ID # and/or Member #

Group # (if on card)

Subscriber Address

Subscriber Phone #

Subscriber Employer Name and Address

Subscriber Relationship to Client

Additional Notes

Name: *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

I HEREBY AUTHORIZE ICSI to furnish the insured’s third party payor with billing information which said third party payor may request concerning my present circumstances. This also applies to clients involved with their county’s Mental Health Plan and their CPC. This includes, but is not limited to, diagnosis, dates of treatment, progress notes, treatment plans, etc. I hereby assign to ICSI all money to which I am entitled for expenses relating to the services performed from time to time, but not to exceed my indebtedness. This will be refunded to me when my bill is paid in full. I understand that I am personally responsible to ICSI for charges not covered by my insurance company. I further authorize photocopies to be made of this authorization and assignment for attachment to any insurance form and authorize the insurance company to accept the copy. This authorization shall continue and be in force until revoked by me in writing.

Parent/Guardian Signature *

Clear

Date *

Date

Responsible Party

Reviewed By:

Integrative Counseling Solutions, Inc. has been selected to provide services to you and your family. No information identifying you or your family will be released or disclosed without written consent by a parent or other legally designated representative. The effective provision of services may require your consent to the exchange of information between Integrative Counseling Solutions, Inc. and the insurance company you are using as a payment agent. You may be asked to sign a specific release of information to any other individual or agencies which staff deems important to communicate with in the best interest of your family.

Integrative Counseling Solutions, Inc. will not knowingly utilize any treatment or procedure, which is experimental, controversial or carries intrinsic risk.

We/I, the undersigned, agree to accept services from Integrative Counseling Solutions, Inc. We agree to cooperate with the requirements for the services our child/family will be participating in during the next twelve months.

We/I, the undersigned, understand that with the proper release, when information needs to be shared quickly, it may be done via fax or computer e-mail. We/I also understand that individual client records may be kept on computer. We/I understand that there is no guarantee that information we disclose in a group or family setting will be held confidential by other members of the group or the family.

We/I understand that in the course of treatment, many subjects will be discussed. Some of these subjects may be, but are not limited to: age, educational achievement, family background, prior treatment efforts, family relationships, marital issues, sexuality, violence, leisure activities, drug/alcohol usage, medical involvement, housekeeping, shopping habits and hygiene.

We/I hereby authorize Integrative Counseling Solutions, Inc. and the identified insurance/funding agent to exchange (both receive and release) information concerning myself or my ward (child or dependent) for the purpose of providing effective treatment services.

We/I understand that it is my responsibility to keep insurance information updated with Integrative

Counseling Solutions, Inc. We/I further understand that we need to provide a copy of our insurance card to Integrative Counseling Solutions, Inc. at the beginning/first appointment of each month.

We/I further agree to pay Integrative Counseling Solutions, Inc., the full balance of any account. I understand that I am responsible for any insurance co-pay, and will pay co-payment at each visit. I further understand that after my insurance company has finalized my claims and made payments to Integrative Counseling Solutions, Inc., I am responsible for any outstanding balances. I also understand that payment is due within 30 days of my receiving a billing statement from Integrative Counseling Solutions, Inc., and/or KASA Practice Solutions on behalf of Integrative Counseling Solutions, Inc. I understand that a 48 hours’ notice is required for change or cancellation of appointment. I understand that if I fail to give 48 hours notice, I will be charged for the cost of the session. If I am unable to pay the full balance, I will contact the billing department at (515) 267-1340 or will talk with my therapist to make acceptable payment arrangements. If this bill is not paid as agreed in full the balance of the bill for care rendered will be processed

This agreement will remain in effect until one year after the involvement with Integrative Counseling Solutions, Inc. ends. This agreement was entered into and signed on: *

Date

Signature *

Clear

We accept these major credit cards:

DISCLAIMER: *

I UNDERSTAND THAT, IF I DO NOT PROVIDE MY CREDIT/DEBIT CARD INFORMATION ON THIS FORM BELOW, I MUST PRESENT IT UPON MY FIRST MEETING WITH MY PROVIDER. FAILURE TO DO SO MAY RESULT IN TERMINATION OF SERVICES (SOME EXCEPTIONS APPLY IF YOUR CHILD IS COVERED UNDER MEDICAID (TITLE XIX).

Cardholder’s Printed Name:

Credit Card Number:

Expiration Date:

Date

CCV (3 digit code on back of card):

I authorize Integrative Counseling Solutions, Inc. to use this credit card for co-pays and any unpaid balance that I owe, including Co-insurance or Deductibles.

Clear

Description of services: My signature below verifies that I have received and read the ICSI handbook. Included in the handbook is a description of the ICSI’s services, specific procedures to be followed, client’s right and responsibilities, appeals process, confidentiality and explanation of the cost for services.

Clients Rights and Responsibilities: I have received information outlining my rights and responsibilities as a client of ICSI. I understand that it is my right to ask questions if I need clarifications or have concerns.

Appeals Process: I have received the information about appeals and grievances. I understand I may ask for help in this process if needed.

HIPAA: The Privacy Rule, which was put into place under the Health Insurance Portability and Accountability Act of 1996 (HIPAA Privacy Rule), establishes a floor of national standards protecting individuals’ identifiable health information. I understand that what I share in the course of treatment at ICSI with my therapist and/or worker is private and confidential and my records are protected under state and federal regulations governing confidentiality. My records cannot be disclosed without written consent, unless otherwise provided for in the regulations, or signed release. I understand that information regarding my care may be shared internally with other professional staff members to assure effective treatment. Information regarding my care will also be provided to our support staff to maintain my records.

Acknowledgement of Child and Dependent Adult Abuse/Neglect Reporting Requirements: I understand that all health and human service providers are required by state law to report suspected abuse or neglect to the appropriate authorities. (If you have any questions about this, please feel free to ask for a better understanding before you signMy signature below acknowledges my understanding.

Consent for Services: I authorize that Integrative Counseling Solution’s, Inc. to perform diagnostic and/or treatment services for (please check the following that apply and provide a full name of the individual for whom you are authorizing service if other than yourself. *

Myself My Child Person for Whom I am a Legal Guardian/Custodian

If you need to cancel an appointment, we require at least 24 hours’ notice. If you do not give us 48 hours’ notice, you may be charged for that appointment.

Service Outcome: The intended outcome of services at ICSI is to reduce the symptoms that are associated with my DSM-V diagnosis. I understand the person who provides my clinical services is not responsible for the outcome of those services.

IF YOU ARE IN A CRISIS AND CANNOT REACH AN ICSI PROFESSIONAL, CALL 911 OR GO TO YOUR NEAREST HOSPITAL EMERGENCY ROOM

Authorizing Signature: I understand that I have the right to revoke the consent, in writing, at any time except to the extent that my provider has taken action in reliance upon the consent.

By signing below I agree to have read and understood the Integrative Counseling Solutions, Inc. handbook. And so give consent of services to the above checked.

This agreement will remain in effect until one year after the involvement with Integrative Counseling Solutions, Inc. ends. This agreement was entered into and signed on:

Date

Signature *

Clear

Printed Name *

Signature of Witness (if applicable

Clear

Witness' Printed Name

Living With (please check all that apply):

Alone Spouse/Relative/Family Friends Foster Home Group Home Care Facility Nursing Home Mental Health Institution Other

Please check the skills you believe your child could use developing:

Social Skills Coping Sills Self-Relaxation Skills Problem Solving Skills Anger Management Skills Pro-Social Communication Skills Skills to Identify Individual Strengths Skills to Identify Triggers to Certain Behaviors Skills to help with Compliance to adult expectations

Behavioral Health Intervention Services (BHIS)

Behavioral Health Interventions Services (BHIS) is a skill-development service for children and adolescents who often display unhealthy functioning or destructive behaviors. Common functioning and behavior targeted through BHIS includes, verbal, or physical aggression, poor listening, poor communication, disrespectfulness, delinquent and destructive actions, low self-esteem etc. BHIS focuses on enhancing positive functioning and behaviors through strengthening the development of social skills, coping skills, communication skills, anger management skills, self-esteem, etc. This service is often a great addition to therapeutic work and can provide your child with more consistent mental, emotional and behavioral care.

Yes, I am interested in hearing more about this service

● 1200 Valley West Drive #508 West Des Moines, Iowa 50266 ●

● Phone: (515) 267-1340 ● Fax: (515) 267-1355 ● www.integrativecs.net ●

CHILD CONSENT FOR TREATMENT

CONSENT FOR TELEMED REMOTE VIDEO SERVICES

Other Parent

CLIENT INFORMATION FORM

In Case of Emergency, Contact:

List of Persons Who Support You/ Your Child :

WORK AND EDUCATION

PRESENTING ISSUES AND MEDICAL HISTORY

RELEASE OF INFORMATION FOR HEALTHCARE PROVIDERS

General Release of Information

RELEASE OF INFORMATION FOR SCHOOLS

SCHOOL BASED CHILD AND ADOLESCENT CONSENT FOR TREATMENT

HOW YOUR MEDICAL DATA IS USED AND WHO CAN ACCESS IT

INSURANCE INFORMATION AND ASSIGNMENT OF BENEFITS

Send Bill To:

SERVICE AGREEMENT / AGREEMENT TO PAY

RECEIPT OF CLIENT HANDBOOK- CONSENT FOR SERVICES

Skill Development Checklist