Associates in Mental Health

1715 C Street Bellingham, WA 98225
Phone: 360-715-2488
Fax: 360-671-1842
Email: associatesinmentalhealth@yahoo.com

CHILD FORMS

If you are a minor or an adult seeking treatment for your minor child, please fill out and print the following five forms and bring them with you to your first appointment.

If you are an adult seeking treatment for yourself, please fill out the forms located on the Adult Forms page.

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Associates in Mental Health
1715 C Street
Bellingham, WA 98225

Child Intake Form

CLIENT INFORMATION

Client Name: Date:

Social Security Number:

Address:

Home Phone:

Sex: Male Female Age: Birth Date:

Mother's Name:

Mother's Address:

Mother's Home Phone:

Mother's Work Phone:

Father's Name:

Father's Address:

Father's Home Phone:

Father's Work Phone:

Child's School: Grade:

Others Living at Client’s Primary Residence: (Include Name, Relationship, Birth Date)

Primary Care Physician: Phone Number:

Referred By:

In Case of Emergency, who should be Notified? Name:

Phone Number: Relationship:

PRIMARY INSURANCE

Person Responsible for Account/Subscriber:

Relationship to Client:

Subscriber’s Birth Date: Social Security Number:

Subscriber's Address:

Subscriber’s Occupation: Business Phone:

Employer:

Insurance Company: Phone Number:

Subscriber ID# or Client’s Individual ID#: Group #:

SECONDARY INSURANCE

Subscriber Name: Birth Date:

Insurance Company: Phone Number:

Subscriber ID# or Client’s Individual ID#: Group #:

Therapist Initials:

Associates in Mental Health
1715 C Street
Bellingham, WA 98225

Child Medical History Form

Please note that some of these questions may not be applicable to your child due to his/her age.

Client Name: Date:

1. Does your child/adolescent have any current acute physical health problems? If yes, describe:

How long has this (these) problem(s) been occurring?

Who is currently treating your child/adolescent for this (these) problem(s):

Do you wish there to be coordination between this office and this individual?

2. Does your child/adolescent have any current chronic physical health problems? If yes, describe:

How long has this (these) problem(s) been occurring?

Who is currently treating your child/adolescent for this (these) problem(s):

Do you wish there to be coordination between this office and this individual?

3. Does your child/adolescent currently consume alcohol and if so how much and how frequently?

Do you suspect your child/adolescent has a problem with alcohol? If yes, describe:

What previous treatment, if any, has your child/adolescent had for alcohol use, and from whom?:

4. Does your child/adolescent currently use drugs recreationally? If yes, describe:

Has your child/adolescent used drugs recreationally in the past? If yes, describe:

5. Does your child/adolescent have a current drug abuse problem (illicit and/or prescription drugs)? If yes, describe:

Has your child/adolescent received treatment for this problem and from whom?

What was the outcome or current status of this treatment?

6. Does your child/adolescent currently consume caffeine and if so how much?

7. Does your child/adolescent currently use nicotine and if so how much?

8. Is your child/adolescent sexually active and do you have concerns about this?

9. Overall how would you rate your child/adolescent's general physical health (include a description of his/her height/weight in comparison to peer group)?

10. Please list any surgeries and/or hospitalizations your child/adolescent has had in the past and the dates:

11. Please list current medications and who is prescribing them:

12. Please list any allergies:

13. Is there any other information that you believe would be helpful to me in my work with your child/adolescent?

_____________________________________________________________________________________

Signature

Therapist Initials:

Associates in Mental Health
1715 C Street
Bellingham, WA 98225

Child Developmental History Form

Client Name: Date:

1. Was this a planned pregnancy?

2. During your pregnancy did you have any of the following? If yes, describe:

   Illnesses

   Infections

   Physical trauma

   Emotional trauma

3. During your pregnancy did you smoke, consume alcohol, or use prescription medications or illicit drugs?
If yes, describe:

4. How much weight did you gain during your pregnancy?

5. When did you first experience in-utero activity?

6. Did you experience pre-eclampsia or toxemia? If yes, describe:

7. Was your child born full-term? If no, describe:

8. Did you have any complications during labor or did your child experience fetal distress? If yes, describe:

9. Did you or your child have any complications during delivery? If yes, describe:

10. Was your delivery: Normal Breech Caesarian

11. Did your child breathe immediately following delivery? Yes No

12. What were your child’s apgar scores?

13. What was your child’s birth weight?

14. Were there any complications following birth or during the first month of life? If yes, describe:

15. Did your child have any feeding problems during the first month of life? If yes, describe:

16. Was your child: Breast fed Bottle fed

17. Did your child gain weight appropriately during the first 6 months of life? Yes No

18. When did your child begin sleeping through the night for a 6 hour stretch?

19. Did your child have any medical problems during the first year of life? If yes, describe:

20. How would you describe your child’s temperament during the first year of life?

21. Were your child’s motor milestones on time? If no, describe:

22. Did your child coo? Yes No Babble? Yes No
Begin using language on-time? Yes No If no, describe what occurred:

Does your child have any language problems at this time?

23. When was your child bladder-trained for day time? Night time?

24. When was your child bowel-trained and were there any problems with this?

25. Is there any history of physical/sexual abuse? If yes, describe:

26. Does your child have any current eating or sleeping problems? If yes, describe:

27. Please describe your child’s toddler period:

28. Please describe your child’s preschool period:

29. Please describe your child’s school years to present time:

30. Please describe how your child gets along with his/her siblings:

31. Please describe how your child gets along with his/her peers:

32. Please describe how your child gets along with his/her parents:

_____________________________________________________________________________________

Signature of person completing form

Therapist Initials:

Associates in Mental Health
1715 C Street
Bellingham, WA 98225

Child Psychiatric History Form

Client Name: Date:

1. Has your child/adolescent seen a psychotherapist, counselor or psychiatrist before? Yes No
If yes, describe with whom, when, for what reasons, and the outcome of treatment:

2. Is your child/adolescent seeing another therapist and/or a psychiatrist at this time? Yes No
If yes, describe with whom, how frequently, and for what reasons:

3. Has your child/adolescent ever been hospitalized for a psychological or psychiatric problem?
Yes No If yes, describe when, where, and for what reasons:

4. Has your child/adolescent ever had problems with depression and/or anxiety? Yes No

5. Has your child/adolescent ever had problems with other psychiatric illness? Yes No
If yes, describe:

6. Please indicate if any of the following is present in your and your child’s other parent’s family tree (including parents, grandparents, aunt/uncles, siblings, etc.). If yes, indicate relationship:

Mother’s Family Tree

Depression
Bipolar Disorder
Anxiety Disorder
Obsessive-Compulsive Disorder
Eating Disorder
Schizophrenia
Dissociative Disorder
Alcoholism
Drug Abuse
Tourette's Syndrome
ADHD
Learning Disabilities
Autism
Mental Retardation

Father’s Family Tree

Depression
Bipolar Disorder
Anxiety Disorder
Obsessive-Compulsive Disorder
Eating Disorder
Schizophrenia
Dissociative Disorder
Alcoholism
Drug Abuse
Tourette's Syndrome
ADHD
Learning Disabilities
Autism
Mental Retardation

7. Is there other psychological or psychiatric history that would be important in my work with your child/adolescent? If yes, describe:

8. Are there social factors (e.g., school changes, relationship issues, moves etc.) that would be important for me to know in my work with your child/adolescent at this time?

_____________________________________________________________________________________

Signature

Therapist Initials:

Associates in Mental Health
1715 C Street
Bellingham, WA 98225

Health Insurance Portability and Accountability Act (HIPPA)

THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND SIGN AT THE BOTTOM.

I. Examples of Uses and Disclosures of Protected Health Information for Payment and Health Care Operations

The providers of Associates in Mental Health may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

• "PHI" refers to information in your health record that could identify you.

• "Treatment, Payment and Health Care Operations"

Treatment is when a provider provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when a provider consults with another health care provider, such as your family physician or another mental health provider.

Payment is when provider obtains reimbursement for your healthcare. Examples of payment are when provider discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of provider’s practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

• "Use" applies only to activities within a provider’s office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• "Disclosure" applies to activities outside of provider’s office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

Provider may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when a provider is asked for information for purposes outside of treatment, payment and health care operations, provider will obtain an authorization from you before releasing this information.

You may revoke all such authorizations of PHI at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) the provider has relied on that authorization; or (2) 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.

III. Uses and Disclosures with neither Consent nor Authorization

Provider may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If provider has reasonable cause to believe that a child has suffered abuse or neglect, provider is required by law to report it to the proper law enforcement agency or the Washington Department of Social and Health Services.

• Adult and Domestic Abuse: If provider has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, provider must immediately report the abuse to the Washington Department of Social and Health Services. If provider has reason to suspect that sexual or physical assault has occurred, provider must immediately report to the appropriate law enforcement agency and to the Department of Social and Health Services.

• Health Oversight: If the Washington Licensing Board subpoenas provider as part of its investigations, hearings or proceedings relating to the discipline, issuance or denial of licensure of state licensed providers, provider must comply with its orders. This could include disclosing your relevant mental health information.

• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that provider has provided to you and the records thereof, such information is privileged under state law, and provider will not release information without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified and you have failed to inform provider that you are opposing the subpoena, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

• Serious Threat to Health or Safety: Provider may disclose your confidential mental health information to any person without authorization if provider reasonably believes that disclosure will avoid or minimize imminent danger to your health or safety, or the health or safety of any other individual.

• Worker’s Compensation: If you file a worker's compensation claim, with certain exceptions, provider must make available, at any stage of the proceedings, all mental health information in my possession relevant to that particular injury in the opinion of the Washington Department of Labor and Industries, to your employer, your representative, and the Department of Labor and Industries upon request.

IV. Other Uses and Disclosures of Protected Health Information

Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

V. Patient's Rights and Provider’s Duties

Patient’s Rights:

• Receive, read, and ask questions about this Notice – You have the right to request and receive a paper copy of the most current Notice of Privacy Practices for Protected Health Information ("Washington Notice Form") from your provider.

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. You must deliver this request in writing to your provider. However, your provider is not required to agree to a restriction you request but will comply with any request granted.

• Cancel prior authorizations – You have the right to cancel prior authorizations to use or disclose health information by giving written revocation to your provider. Your revocation does not affect information that has already been released. It also does not affect any action taken before your provider has your revocation. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are receiving treatment. Upon your written request, your provider will send your PHI to another address.)

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in your provider’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.Upon your request, your provider will discuss with you the details of the request and denial process.

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your provider may deny your request. On your request, your provider will discuss with you the details of the amendment process. You may write a statement of disagreement if your request is denied. It will be stored in your medical record and included with any release of your records.

• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). This will not include disclosures to third-party payers. You may obtain this information without charge once every 12 months. Your provider will notify you of the cost involved if you request this information more than once in 12 months.

Provider’s Duties:

• Your provider is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.

• Your provider reserves the right to change the privacy policies and practices described in this Notice. Unless your provider notifies you of such changes, however, your provider is required to abide by the terms currently in effect.

• Your provider has the right to change his/her practices regarding the protected health information he/she maintains. If your provider make changes and you are an active patient in his/her practice, he/she will provide you with a copy of the updated Notice at your first visit after the change. You may always receive the most recent copy of this Notice by calling your provider and asking for it or by visiting your provider’s office to pick one up.

VI. To Ask for Help or Report a Grievance

If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:

Letisha Stokes, Office Manager
Associates in Mental Health
1715 C Street
Bellingham, WA 98225
360-715-2488 extension 0

If you believe your privacy rights have been violated, you may discuss your concerns with your provider or the above noted person. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

VII. Web Site

Associates in Mental Health has a Web Site that provides information about your provider. For your benefit, this Notice is on the Web Site at this address: www.amhinfo.com.

VIII. Effective Date

This notice is effective as of April 14, 2003.

_____________________________________________________________________________________

Signature

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