Patient’s First Name

Patient’s Last Name

Gender

Male Female Non-Binary

Date Of Birth

Social Security Number

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Best Time To Call You

Morning Early Afternoon Late Afternoon Early Evening

Phone

Emergency contact:

Name

Relationship

Phone Number

If patient is younger than 18 years old

Mother's Name

Father's Name

Patient Insurance Information

Insurance Carrier

ID#

SSI Benefits

Yes No

DISABILITY BENEFITS

Yes No

If Referred

Name

Phone

Who Made this Appointment?

Name

Phone

Employment

Employer

Position

School

Medical History

Primary Physicians Name

Phone Number

Psychiatry Name

Phone Number

Have you ever received mental health treatment?

yes no

Current Medications

Medicine Name

For

Bill Info.

Diagnosis Code

Billing Code

By clicking this box, I understand or I submit my electronic signature.

I agree to the terms and conditions.

CANCELLATION / NO SHOW POLICY FEE FORM

To our patients: Therapy is a continuous process, which necessitates your commitment to attendance every week, or the necessary amount of times you have arranged with your therapist. We are asking our patients to let us know 24 hours in advance if they cannot come to their appointment. Please call your therapist or the office so we can discuss a makeup session. If you cannot arrange a makeup session, you will be charged $40.00. Additionally, if two consecutive appointments are missed the same appointment time is not guaranteed.

IMPORTANT NOTICE FOR OUR PATIENTS

All patients and/ or representatives will be held responsible for notifying our practice immediately of any changes or terminations with current insurances. Failure to do so will hold patient responsible for all therapy session payments that were not covered by the insurance on file. Thank you for your cooperation.

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon the execution of this consent.

May we phone, email, or send a text to you to confirm appointments.

yes no

May we leave a message on your answering machine at home or on your cell phone.

yes no

May we discuss your medical condition with any member of your family.

yes no

By clicking this box, I understand or I submit my electronic signature.

I agree to the terms and conditions.

Presenting Problems and Concerns

PLEASE TAKE YOUR TIME TO ANSWER ALL APPLICABLE QUESTIONS

Describe the problem that brought you here today

Has your child ever had thoughts, made statements, or attempted to hurt him/herself?

Has your child ever had thoughts, made statements, or attempted to hurt someone else?

Has your child recently been physically hurt or threatened by someone else?

Has your child ever restricted their eating or eaten in a way that made you uncomfortable?

Family and Developmental History

If the parents are separated or divorced, what is the current child custody/visitation arrangement?

Is your child currently the subject of a custody case?

Yes No

Has your child ever been a ward of the court with SCF/DCFS guardianship?

Yes No

Does your child have any legal offenses on record or pending in the courts?

Yes No

Were there any medical problems during the pregnancy or birth of your child?

Did the biological mother use any tobacco, medication, street drugs, or alcohol while pregnant with this child?

Did your child have any developmental delays in early childhood (crawling, walking, talking, toileting, etc.)?

Substance Use History

Please answer yes or no for any of the substance type use below, and if yes, list the frequency and amount of use.

Durgs

Current Use (last 6 months)

Past Use

Has your child had withdrawal symptoms when trying to stop using any substances? I

Has your child ever had problems with work, relationships, health, the law, etc. due to his/her substance use?

Medical Information

Date of last physical exam:

Has your child experienced any of the following medical conditions during his/her lifetime?

Current Prescription Medications

Medicine Name

Dosage

Date First Prescribed

Prescribed By

Prescribed For

Previous Mental Health Treatment

Current over-the-counter medications (including vitamins, herbal remedies, etc.):

Interpersonal/Social/Cultural Information

Please describe your child’s social support network (check all that apply):

To which cultural or ethnic group does your child belong?

If your child is experiencing any difficulties due to cultural or ethnic issues, please describe:

How important are spiritual matters to your child?

Not at all Little Somewhat Very much

Would you like spiritual/religious beliefs to be incorporated into your child’s counseling?

Yes No

Please describe your child’s strengths, skills, and talents?

Describe any special areas of interest or hobbies (art, books, physical fitness, etc.):

School Information

Current grade/placement:

Does your child have an after-school provider?

Has your child ever repeated or skipped a grade?

Has your child ever received Special Education services? If yes, please describe services received and reason for services:

What does your child’s teacher(s) say about him/her?

Thank you for your time in answering these questions. It will help me get to know some things about you and/or your child that will help me right away in providing helpful treatment. Please use this space to tell me anything else you think I should know about you or your child.

Signature

Upload documents

Name

Date

Terms and Conditions

by clicking here, I understand or I submit my electronic signature

Child Patient Registration

Emergency contact:

If patient is younger than 18 years old

Patient Insurance Information

If Referred

Who Made this Appointment?

Employment

Medical History

Current Medications

Bill Info.

CANCELLATION / NO SHOW POLICY FEE FORM

IMPORTANT NOTICE FOR OUR PATIENTS

HIPAA Compliance Patient Consent Form

By signing this form, I understand that:

Presenting Problems and Concerns

Family and Developmental History

Substance Use History

Medical Information

Current Prescription Medications

Interpersonal/Social/Cultural Information

School Information

Signature

HIPAA

Protected

Licensed

Therapists

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