Child Intake Form

Child Intake Form

Patient Demographics

Emergency Contact

Mental Health History

If yes please provide the Professional’s Name and dates of treatment below:

Parent/Legal Guardian Information

Medical History

Please list ALL current medications:

Responsible Party

Employee Assistance Program (EAP)

If yes, please provide the following information:

Primary Insurance

Secondary Insurance

Please Select One
I understand that the following charges are not covered by insurance: $20-Medication Refill Fee, $75-No Show/Late Cancellation Fee (we require 24 hours notice for a cancellation) $90-Bariatric Form Writing Fee. $120 (per hour)-Completion of Paperwork/ Letter Writing Fee. For other fees not covered by insurance please refer to the financial agreement. l I further understand that I may request a full copy of DBH’s financial agreement at any time.

Have you had any of the following problems in the last month?
(Please have child/adolescent answer questions)

Lifestyle Questions

Nutrition
Exercise
Sleep
Smoking
Social Network
Hobbies
Stress Management
If yes, answer the following questions
Alcohol
Non Prescription Drugs
Spiritual Practices

Consent for Treatment

I, the undersigned, am the parent/legal guardian of the patient, do voluntarily consent to psychiatric/behavioral health assessment and/or treatment for him/her.

By signing below, I authorize Dominion Behavioral Healthcare to provide psychiatric and/or behavioral health assessment and exams, treatment, and/or diagnostic procedures which now, or during the course of my child’s treatment, be- come advisable. I understand that the purpose, potential risks and benefits, and alternatives to any treatment, as well as the risks of not having treatment, will be explained to me upon my request, and that I can always decline treatment.

I understand that while my child’s treatment will be designed to help me, there is no guarantee of a successful outcome.

Psychotherapy involves risks, such as but not limited to, the development or worsening of emotions such as anxiety, sadness and anger. I understand that this is a normal response to working through life experiences and that these reactions should be discussed with my therapist or physician.

Treatment with Medication also has certain risks, varying with the type of medication prescribed, which will be ex- plained to me. I know that taking a medication of any kind always carries the risk of a potentially fatal allergic reaction. I understand that it is my responsibility to make my physician aware of any health conditions that my child has or that develop over the course of treatment, and to make my child’s physician aware of any other medications, including over- the-counter medications or herbal supplements that he/she is taking. I also understand that discontinuation of medication should be discussed in advance with my child’s physician.

I understand that it is my responsibility to inform my child’s physician or therapist if my child feels worse in response to any treatment provided, including but not limited to, the development or worsening of suicidal ideation, depression, agitation, anxiety, insomnia, irritability or mania, especially if these reactions are new, severe, or abrupt in onset.

I understand that as part of my child’s mental health care, Dominion Behavioral Healthcare originated and will maintain paper and/or electronic records describing treatment, testing results and forms, correspondence and insurance information. Except when required by law, this information cannot be disclosed without my written consent. I may revoke any authorization for disclosure at any time except if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

I further understand that I may request a complete copy of Dominion Behavioral Healthcare’s Privacy Practices at any time.

I understand that my child’s treating clinician is required by law to maintain privacy of his/her mental health record and to provide me with notice of their legal duties and privacy practices with respect to my child’s mental health record. The treating clinician has the right to change those privacy policies and practices with notification to you in writing.

I understand that at no time, am I permitted to record video and/or audio of my child’s sessions with their treating clinician.

I understand that I have the right to disagree with decision made and I can make a formal complaint to a Dominion Be- havioral Healthcare Privacy Officer at (804) 270-1124. A written complaint can be made to the Secretary of the U.S. Department of Health and Human Services.

I understand that this notice is in effect beginning January 1, 2018. If there are any changes to this notice while my child is still in treatment at DBH then I will be notified in person and writing about such changes.

Authorization to Release Information

In accordance with HIPAA privacy laws, a signed consent form is required to release information in any form about your care. This authorization allows us to communicate when needed or requested regarding scheduling, insurance or billing information, as well as routine or emergency contact. This authorization may be rescinded or amended at any time that you choose.

Please use the space below to identify any family, friend or medical professional with whom you may want us to have contact.

I, certify that I am the legal guardian of the patient and give permission for Dominion Behavioral Healthcare to communicate with the following persons about my child’s treatment:

Please initial

Consent for Coordination of Care

*In order to provide the best care possible, your physician and/or clinician would like to be able to communicate with your other treating medical professionals.

*Most insurance companies require this information exchange.

*Please check one of the following and sign.

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