Child Intake Form

Triad Counseling & Clinical Services, PLLC
5587 D Garden Village Way, Greensboro, NC 27410
1623 York Avenue, Suite 104, High Point NC, 27265

Client (Under 18 years old) Information Form

If parent/guardian is completing this form please answer questions from your child’s perspective

Date

Full Name

Preferred Name

Who referred you?

Date of Birth

Age

Gender

Social Security #

Address

Street Address City State / Province / Region ZIP / Postal Code

Primary Contact Number

Secondary Contact Number

Email address

Please indicate where we have permission to leave a message:

Primary Phone

Secondary Phone

Please choose one (1) option for your appointment reminder

Voicemail

Text

No reminder needed

voicemail

Text

Please indicate you have read

I understand that email and texting, while confidential, may not be secure to third-party intrusion.

Parent/Guardian 1

Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth

Employer

Home Phone

Work Phone

Cell Phone

Please indicate where you prefer to be contacted

home phone

work phone

cell phone

Please indicate where we have permission to leave a message

home phone

work phone

cell phone

Parent/Guardian 2

Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth:

Employer

Home Phone

Work Phone

Cell Phone

Please indicate where you prefer to be contacted

home phone

work phone

cell phone

Please indicate where we have permission to leave a message

home phone

work phone

cell phone

Client Education/Employment

Current Grade

School

Employment

None

Part-Time

Full-Time

Occupation

How Long?

Afterschool Activities (if any)

Family History

Please list information about client’s immediate family members

Relative (mother, father, siblings)

Name

Age

Deceased? (yes/no)

Current City, State

Relationship (excellent, good, fair, poor)

Physical/Mental Illness

Any other family history of psychological/psychiatric concerns? (i.e. grandparents, aunts/uncles, etc. )?

Are the clients parents married?

Yes

If no, please indicate parents relationship status

If no, mother remarried?

Yes

Father remarried?

Yes

Stepfather/Stepmother Name(s)

What are the current living arrangements for the client?

If there is a custody agreement, who has primary custody?

Family Spiritual/Religious Practices (if any)

Client Spiritual/Religious Practices (if any)

Personal Health History

In general, the client’s health is

Client’s Physician

Date of last Physical Exam

Client’s Psychiatrist (if applicable):

Date of last visit

Please indicate if the client has any serious medical conditions and age of onset

Does the client have any allergies?

Does the client have any developmental concerns/differences?

Does the client have any medical conditions that required hospitalization?

Yes

Please Describe

Has the client been hospitalized for psychiatric or substance abuse issues?

Yes

Hospital/Treatment Center

Location

Dates of Treatment

Please list all current medications for client

Medication

Dose

Frequency

Reason for Medication

Prescribing Physician

Please describe the client's previous counseling history

Dates of Service

Counselors Name

Reason for Services/Outcome

Current Health Information

Briefly describe your reason for/anticipated outcome in seeking counseling services at this time

TO BE COMPLETED BY PARENT/GUARDIAN

Which Best Describes The Client?

1. Destroys/destroyed property

Never

Sometimes

Often

2. Is/was unhappy or sad

Never

Sometimes

Often

3. Behavior causes/caused problems in school

Never

Sometimes

Often

4. Has/had temper outbursts

Never

Sometimes

Often

5. Worrying prevents them from doing things

Never

Sometimes

Often

6. Worries/worried about almost everything

Never

Sometimes

Often

7. Has repeated unwanted thoughts

Never

Sometimes

Often

8. Engages in repeated, ritualized behaviors

Never

Sometimes

Often

9. Feels nervous and shaky (dizzy)

Never

Sometimes

Often

10. Feels worthless or inferior

Never

Sometimes

Often

11. Changes mood quickly

Never

Sometimes

Often

12. Difficulty with concentrations

Never

Sometimes

Often

13. Frequent stomach or intestinal distress

Never

Sometimes

Often

14. Difficulty falling asleep

Never

Sometimes

Often

15. Difficulty staying asleep

Never

Sometimes

Often

16. Difficulty at home with siblings

Never

Sometimes

Often

17. Difficulty at home with parents

Never

Sometimes

Often

18. Difficulty at school (academics)

Never

Sometimes

Often

19. Difficulty at school (socially)

Never

Sometimes

Often

20. Difficulty at school (behaviorally)

Never

Sometimes

Often

21. Bullies or has bullied others

Never

Sometimes

Often

22. Is/was bullied by others

Never

Sometimes

Often

23. Has experienced significant weight gain

Never

Sometimes

Often

24. Has experienced significant weight loss

Never

Sometimes

Often

25. Restricts/has restricted eating

Never

Sometimes

Often

26. Engages/has engaged in over exercise

Never

Sometimes

Often

27. Feels angry or irritable

Never

Sometimes

Often

28. Engages/has engaged in self-injury

Never

Sometimes

Often

29. Has experienced suicidal thoughts

Never

Sometimes

Often

30. Has attempted suicide

Never

Sometimes

Often

31. Has experienced homicidal thoughts

Never

Sometimes

Often

32. Do you think your child drinks alcohol?

Yes

33. Do you think your child smokes marijuana/uses other drugs?

Yes

If you answered ‘yes’ to question #32, how many alcoholic drinks do you think the client has had in the past week?

If you answered ‘yes’ to question #33, how many days do you think the client has used marijuana and/or other drugs?

Does the client have a history of abuse or trauma?

Yes

Please Describe

Do you have a history of abuse or trauma?

Yes

Please Describe

In the past 6 months, how often have you had to miss school/work due to the physical or mental health concerns of the client?

In the past 6 months, how often has your family life been disrupted because of the physical or mental health concerns of the client?

What strengths do you believe the client has?

How do you think the client would answer the following statements?

I feel good about myself.

Strongly Agree

Agree

Disagree

Strongly Disagree

I can deal with my problems.

Strongly Agree

Agree

Disagree

Strongly Disagree

I am able to accomplish the things I want

Strongly Agree

Agree

Disagree

Strongly Disagree

I have friends or family that I can count on.

Strongly Agree

Agree

Disagree

Strongly Disagree

Is there any additional information you think it would be helpful for the therapist to know in providing services to the client?

Please initial the following statements regarding payment, release of information, and confidentiality

______ I understand that all fees from professional services rendered are my responsibility, including services not covered by insurance. I am aware that this office files my insurance as a courtesy, and services must be paid when rendered.

______ I hereby authorize Triad Counseling and Clinical Services, PLLC to release any information necessary to process insurance claims concerning my diagnosis and treatment, and I authorize payment of medical/psychological benefits to Triad Counseling and Clinical Services, PLLC.

______ I understand that Triad Counseling and Clinical Services, PLLC, is ethically and legal required to report to legal authorities information I give about ongoing abuse of children, disabled, and elderly persons and imminent physical danger I present to myself or others because of psychological factors.

Client’s Signature (Parent/Guardian)

Max. file size: 100 MB.

Date

Release of Information

Scheduling or Billing

You can authorize the release of your private health information to others for scheduling or billing purposes. Keep in mind that we cannot discuss your records without your written consent. Please complete the section below if you would like to allow access to your records.

Please initial the following:

______ I do not authorize access to my private health information (PHI) at this time,

OR ,______ I authorize access to my private health information (PHI) to the following individual other than myself

Name

Relationship

in the following forms and purposes only

Scheduling (making, changing, or verifying appointments)

Billing (accessing verbal and written detailing in regards to payments, session dates, and general billing inquiries, including allowing others to make payments on my behalf)

Client’s Signature (Parent/Guardian)

Max. file size: 100 MB.

Date

Triad Counseling & Clinical Services, PLLC
5587 D Garden Village Way, Greensboro, NC 27410
1623 York Avenue, Suite 104, High Point NC, 27265

CONSENT TO DISCLOSE INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS & ACKKNOWLEDGEMENT OF PRIVACY PRACTICES

I hereby consent to the use or disclosure of my individually identifiable health information (“protected health information” or PHI), excluding psychotherapy notes, by Triad Counseling and Clinical Services, PLLC (Provider) in order to carry out treatment, payment, or health care operations (TPO). My specific authorization must be obtained for disclosure of my PHI, including summary of psychotherapy notes, for purposes other than TPO, except in special situations. I have reviewed the Notice of Privacy Practices for a more complete description of the potential disclosures of such information.

I have the right to inspect and obtain a copy of my medical/mental health records, although I understand the Provider has the right to deny such request under certain circumstances. I have the right to have a denial to inspect reviewed by a “reviewing official.” A reasonable fee may be charged for providing a copy of my records. I have the right to request amendments to the information in my medical/mental health records, although I understand the Provider has the right to deny such request. I have the right to request an accounting of disclosures of my PHI for purposes other than TOP and those for which I provided authorization. I may submit a written privacy complaint to 5587 D Garden Village Way, Greensboro, NC 27410 or to the U.S. Secretary of the Department of Health and Human Services, without any action being taken by the Provider against me without any change in my treatment.

Provider reserves the right to change the terms of its Notice of Privacy Practices at any time. If the terms of the Notice of Privacy Practices are changed, I may obtain a copy of the revised Notice by requesting a copy.

I retain the right to request that the Provider further restrict how my protected health information is used or disclosed to carry out treatment, payment, or health care operations. The Provider is not required to agree to such requested restrictions; however, if the Provider does agree to the requested restriction(s), such restrictions are then binding on the Provider

At all times, I retain the right to revoke this Consent. Such revocation must be submitted to the Provider in writing. The revocation shall be effective except to the extent that the Provider has already taken action in reliance on the Consent.

The Provider may refuse to treat me if I (or authorized representative) do not sign the Consent portion of this form (except to the extent that the Provider is required by law to treat individuals). If I (or authorized representative) sign the Consent portion and then revoke Consent, the Provider has the right to refuse to provide further treatment to me as of the time of revocation (except to the extent that the Provider is required by law to treat individuals).

Please initial the following:

I ______ HAVE HAD AN OPPORTUNITY TO REVIEW THE PROVIDER’S NOTICE OF PRIVACY PRACTICES.

I ______ CONSENT TO THE RELEASE OF PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.

OR I ______ DO NOT CONSENT TO THE RELEASE FOR PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.

Please Print Name

Client’s Signature (or authorized representative)

Max. file size: 100 MB.

Date

Representative’s Authority to act on behalf of the Patient

For office staff use only:

Acknowledgement of Privacy Practices was not obtained because: ___________ HIPAA 11/2019

Consent for the Release of Mental Health Information

This form is used to be able to discuss or release information to you (or your child’s) primary care doctor only, in order to coordinate treatment.

If you wish for information to be released to the primary care doctor only, please fill in the name of that doctor, check by the authorization line and sign and date the form.

If you DO NOT wish for information to be released to the primary care doctor, check by the decline line and sign and date the form.

Client Name

Date of Birth

Mental Health Provider

Name

Address

Phone

Primary Care Physician

Name

Address

Phone

____ I authorize the release of relevant treatment information to the provider(s) named above. I understand that these records are confidential and cannot be disclosed without my written authorization, except as otherwise provided by law. My consent may be revoked at any time, and expires one year from the date signed.

____ I decline the release of treatment information to my Mental Health Provider or Primary Care Physician

Client’s Signature (Parent/Guardian)

Max. file size: 100 MB.

Date

Relationship to Client

Triad Counseling & Clinical Services, PLLC
5587 D Garden Village Way, Greensboro, NC 27410
1623 York Avenue, Suite 104, High Point NC, 27265

Parent/Guardian Information Form

Date

Full Name

Date of Birth

Gender

Relationship to Client

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Other Phone

Email Address

Please choose one (1) option for appointment reminder

Text

Voicemail

Text

Voicemail

Emergency Contact

Relationship

Phone

Is there any parental history of family psychological/psychiatric concerns? If so, please specify

Is there any parental history of alcohol/substance abuse? If so, please specify

Is there any parental history of psychiatric/substance abuse treatment? If so, please specify when and what type

Is there any parental use of medication for psychological concerns? If so, please specify

Do you think you and your child have different goals for counseling at this time?

Late Cancellation and No Show Notice

TCCS client, please note that our no show and late cancellation fee is $125.00. This charge is not billable to insurance, so for a missed appointment it will be the full amount.

Appointments that are cancelled within the 24hr time window are not subject to this fee.

Please make every attempt to keep your appointment or cancel within 24hrs.

Please sign this form to agree that you understand this policy and that you are responsible for this fee if it is assessed to your account.

Thank you,
TCCS Management

Client signature

Max. file size: 100 MB.

Date

Name

This field is for validation purposes and should be left unchanged.

Client (Under 18 years old) Information Form

Parent/Guardian 1

Parent/Guardian 2

Client Education/Employment

Family History

Personal Health History

Current Health Information

TO BE COMPLETED BY PARENT/GUARDIAN

Which Best Describes The Client?

How do you think the client would answer the following statements?

Please initial the following statements regarding payment, release of information, and confidentiality

Release of Information

Scheduling or Billing

CONSENT TO DISCLOSE INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS & ACKKNOWLEDGEMENT OF PRIVACY PRACTICES

Consent for the Release of Mental Health Information

Parent/Guardian Information Form

Late Cancellation and No Show Notice

Greensboro Location

High Point Location

Client (Under 18 years old) Information Form

Parent/Guardian 1

Parent/Guardian 2

Client Education/Employment

Family History

Personal Health History

Current Health Information

TO BE COMPLETED BY PARENT/GUARDIAN

Which Best Describes The Client?

How do you think the client would answer the following statements?

Please initial the following statements regarding payment, release of information, and confidentiality

Release of Information

Scheduling or Billing

CONSENT TO DISCLOSE INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS & ACKKNOWLEDGEMENT OF PRIVACY PRACTICES

Consent for the Release of Mental Health Information

Parent/Guardian Information Form

Late Cancellation and No Show Notice

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Greensboro Location

High Point Location