Intake Form for Child/Adolescent Psychotherapy. Child s name: DOB/Age: Address: Phone number: (C) (H)

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1 Intake Form for Child/Adolescent Psychotherapy Child s name: DOB/Age: Address: Phone number: (C)(H) Child primarily lives with: Both parents Mother Father Other Legal Guardian Name: DOB: Address: Phone: (C) (H) (W) Employer: Please list others living in guardian s home, ages, and relationship to child: Mother Name: DOB: Address: Phone: (C) (H) (W) Employer: Custody: Please list others living in mother s home, ages, and relationship to child: Father Name: DOB: Address: Phone: (C) (H) (W) Employer: Please list others living in father s home, ages, and relationship to child:

2 Please describe custody and the child s current living arrangements: Is there any legal involvement with your child? Yes No If so, please describe: Please bring copies of any court orders that impact your child. Child s name: DOB/Age: Who are your child s significant others living with your child? Please list their names, ages, relationships, grades, and jobs if applicable: Who are your child s significant others not living with your child? Please list their names, ages, relationships, grades, and jobs if applicable: School attending and grade level: Has an IEPYesNo Child s job and employer (if applicable): How were you referred:

3 Reason(s) for seeking therapy: What goals do you have for therapy? Have you sought mental health treatment before for your child? Yes No If so, when and with whom? Has there been any history or suspicion of physical, sexual, or emotional abuse? (If so please explain) Have there been any suicide attempts? (If so, explain) Child s name: DOB/Age: Insurance Information Company Name: Policy Holder s Name: Policy NumberGroup NumberPhone Number By completing this form, my signature indicates that the information provided is truthful and accurate. Form completed by: Date: (Signature)

4 Medical and Health History For Child/Adolescent Name: Date: List any allergies you have: None Primary Care Physician: Address: City: State: ZIP: Primary Care Physician s phone number: () Date of your most recent physical examination: Please list all current medications and dosages: Name of Medication Dosage Name of Prescribing Doctor When did you start taking it? Please list all current or past health problems, and any major operations: Current Past

5 List all therapists you have seen, and dates you saw them: List any substance abuse treatment or inpatient psychiatric treatment you have had, and the dates: Have you had past psychiatric hospitalizations? Yes No If yes, please state where, when, and reason for hospitalization Please describe any psychiatric disorders in immediate and/or extended family: Child s name: DOB/Age: Please indicate which of these substances you currently use or have used in the past: Substance Amount used How often? Cigarettes Alcohol Pills not prescribed for me Marijuana Cocaine or crack LSD Methamphetamine Ecstasy Mushrooms Heroin Other (please list): Do you consider any of your substance use to be a problem? Yes No If yes, please describe: Please indicate if you are having any of the following problems, or if you had them in the past: I have I had it this now in the past Difficulty falling asleep or staying asleep

6 Sleeping too much Change in appetite, weight loss, or weight gain Frequent crying Panic attacks or anxiety attacks Thoughts of killing or hurting self Attempts to kill or hurt self Problems concentrating Problems remembering things Periods of daily sadness lasting more than two weeks Startle easily Can t stop remembering upsetting past events Difficulty controlling temper Physically hurt other people Break things sometimes Worry a lot Feel tired almost every day Feelings of unreality Made self throw up in order to lose weight Used laxatives or exercised excessively to lose weight Often feel like an outsider Worry that something is wrong with body Frequent arguments with the people living with Hear voices inside my head Other (please list): By completing this form, my signature indicates that the information provided is truthful and accurate. Form completed by: Date: (Signature)

7 Sierra Dator, MSW, LCSW Licensed Clinical Social Worker LCS East Cotati Avenue, Suite G, Cotati, CA Informed Consent For Counseling Services Client s Name: Today s Date: Date of Birth: Please read carefully. The purpose of this consent form is to provider you with the information about myself and my practice policies and to help insure your needs as an informed client are met. Please feel free to talk with me regarding any questions or concerns you may have regarding this information. Education and Qualifications I am a Licensed Clinical Social Worker in the State of California. I received my Bachelor s Degree in Social Work at Keuka College, Keuka Park, NY and my Master s Degree in Social Work at the State University of New York at Buffalo. My experience includes work with children, adolescents, individuals, and families. I am a member of the National Association of Social Workers. I also receive ongoing training several times a year through workshops and seminars.

8 The Therapy Relationship The essential part of entering into counseling is developing a trusting, honest relationship. In order for us to work well together, it is important that we communicate openly with each other. Part of the therapy process involves exploring what is true for you as each person is unique. A large piece of my work is to help you discover what works best for you and your life circumstances. Risks and Benefits of Therapy Psychotherapy is a way of talking through your problems in order to begin resolving them. You will need to take an active part in psychotherapy by working on and thinking about the things you talk about with me. Psychotherapy has been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and feeling much less distressed. However, there are no guarantees of what you will experience, and at times a psychotherapy session may leave you with unhappy feelings. I will be committed to this process and work hard for you, and I will ask you to do the same. I am always willing and encourage discussion regarding your progress in therapy. Legal and Ethical It is without coercion that the client/parent/guardian consents to treatment. The client/parent/guardian is entitled to receive information from me about methods of therapy, the techniques used, and the therapy fee structure. Please ask if you would like to receive this information. Sierra Dator, MSW, LCSW Licensed Clinical Social Worker LCS23317 Confidentiality In keeping with ethical standards of the National Association of Social Workers and state and federal law, all services I provide are kept confidential and will not be released to any third party without your written consent, except when required or permitted by law. At times, I may consult as needed with colleagues about the best way to provide the assistance you might need. During these times, I discuss the case without using personal identifying information. As required by social work practice guidelines and current standards of care, I keep records of your therapy. Neither the fact that you seek therapy, nor any information disclosed in the therapy sessions will be disclosed except as requested by you and as noted in the exceptions below. I have a legal responsibility to disclose patient information without prior consent when a patient is likely to harm himself/herself or others, when there is reasonable suspicion of abuse of children, dependent adults or the elderly, when the client lacks the capacity to care for him or herself and when there is a valid court order for the disclosure of client files. By signing this form you also give me permission to communicate with the Emergency Contact that you have designated if I believe that you are at risk. If you choose to make a claim your insurance company some information will be provided to them after you sign a release. Please discuss any concerns or question you may have about confidentiality. Treating a Minor When treating a minor, my policy is to receive consent from all legal guardians. In the case of separation or divorce, I need documentation and a signature from the legal guardian of the minor involved. The same laws apply to minors regarding maintaining confidentiality, except in the following circumstances

9 A minor tells me they plan to cause serious harm or death to themself, and I believe the minor has the intent and ability to carry out this threat in the very near future. I must take steps to inform the parent or guardian of what the minor has told me and how serious I believe this threat to be. I must make sure that the minor is protected from harming himself or herself. A minor tells me they plan to cause serious harm or death to someone else who can be identified, and I believe the minor has the intent and ability to carry out this threat in the very near future. In this situation, I must inform the parent or guardian, and I must inform the person who the minor intends to harm, and possibly the proper authorities. The minor is doing things that could cause serious harm to himself or herself or someone else, even if the minor does not intend to harm himself or herself or another person. In these situations, I will need to use my professional judgment to decide whether the parent or guardian should be informed. A minor tells me they are being abused-physically, sexually or emotionally or that they have been abused in the past. In this situation, I am required by law to report the abuse to the proper authorities. A minor is involved in a court case and a request is made for information about the minor s counseling or therapy. If this happens, I will not disclose information without the parent or guardian s written agreement unless the court requires me to. I will do all I can within the law to protect the minor s confidentiality, and if I am required to disclose information to the court, I will inform the minor that this is happening. Sierra Dator, MSW, LCSW Licensed Clinical Social Worker LCS23317 Couples and Families I have a no secrets policy when working with couples or families. This means that I encourage you to discuss any thoughts or feelings directly during our sessions and not privately with me. I reserve the right to disclose or encourage disclosure of any secrets shared outside of the family/couple session. Attendance and Cancellation Policy Consistency is essential for the overall progress and effectiveness of therapy. I will be saving time and rom for you, so please be on time. I require at least 24 hours notice if you must cancel a session, otherwise you will be billed at the regular agreed upon fee. I will extend the same courtesy to you. It might happen that something occurs where I will need to reschedule our session. If I am unable to give you 24 hours notice, you will receive credit towards your next session. Fees My fee is $90.00 for a 50-minute session. There are times when I accept a reduced fee due to financial hardship. The fee will be discussed and set prior to our first session together. Payment is to be made at the beginning of each session. I accept some insurances and can discuss with you if I am preferred provider. If using an insurance please verify that psychotherapy with me is covered by your insurance policy. Termination The length of treatment and the timing of the eventual termination of treatment depend on the specifics of the treatment plan and the progress achieved. It is a good idea to plan for termination

10 in collaboration with the therapist. The therapist will discuss a plan for termination with the client as the completion of the treatment goals are approached. The client may discontinue therapy at any time. If the client or therapist determines that the client is not benefiting from treatment, either party may elect to initiate a discussion of treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing the treatment plan, or terminating the therapy. Contact and After Hours Emergencies My voice mail is available 24 hours a day. During business hours I check it regularly. However, in the case of an emergency, do not leave a message on my voic . Instead call either Psychiatric Emergency Service at or 911. Please sign below to indicate that you understand and agree to participate in therapy in accord with the above policies. Print NameDate SignatureDate Print NameDate SignatureDate Sierra Dator, MSW, LCSW Licensed Clinical Social Worker LCS East Cotati Avenue, Suite G, Cotati, CA sierradator@yahoo.com Consent to Treat a Minor I,, give (parent(s)/legal guardian) permission to Sierra Dator, LCSW, to provide psychotherapy to the following minors: (Minor s name) (Minor s name) SignatureDate

11 SignatureDate Authorization to Release Protected Health Information I hereby authorize Sierra Dator, LCSW to release exchange protected health information with: Name Mailing Address Phone Number Regarding: Name Date of Birth Phone Number Method of disclosure and/or exchange: Verbal Copies of Records Letter Proof of Attendance Other Types of information included: Any and/or All Information Necessary Diagnosis Treatment Plan Symptoms Dates of Treatment Summary of Treatment I authorize the disclosure of protected health information for the following purposes:

12 The specific uses and limitations of my protected health information by Recipient are as follows: I understand that Sierra Dator, LCSW cannot condition treatment upon me signing this authorization. I understand that I have a right to receive a copy of this authorization and that any cancellation or modification of it must be in writing. I understand that I have the right to revoke this authorization at any time unless Sierra Dator, LCSW has taken action in reliance upon it. I also understand that such revocation must be in writing and received by Sierra Dator, LCSW to be effective. I understand that the health information disclosed pursuant to this authorization may be subject to re-disclosure by Recipient and that the Federal Privacy Rule may no longer protect such information, although the re-disclosure of such information may be protected by applicable California law. This authorization shall remain valid until: Authorization Expiration Date Signature of Client/Legal Guardian Client/Legal Guardian Name (Print) Date HIPPA: Health Insurance Portability Accountability Act of 1996 Notice of Privacy Practices I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. II. I HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI) I am legally required to protect the privacy of your PHI, which includes information that can be used to identify you that I've created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. I must provide you with this Notice about my privacy practices, and such Notice must explain how, when, and why I will "use" and "disclose" your PHI. A "use" of PHI occurs when I share, examine, utilize, apply, or analyze such information within my practice; PHI is "disclosed" when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, I am legally required to follow the privacy practices described in this Notice. However, I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies, I will promptly change this Notice and post a new copy of it in my office and on my website. You can also request a copy of this Notice from me, or you can view a copy of it in my office or at my website, which is located at III. HOW I MAY USE AND DISCLOSE YOUR PHI. I will use and disclose your PHI for many different reasons. For some of these uses or disclosures, I will need your prior authorization; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category. A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons:

13 1. For treatment. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your care. For example, if a psychiatrist is treating you, I can disclose your PHI to your psychiatrist in order to coordinate your care. 2. To obtain payment for treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan to get paid for the health care services that I have provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process my health care claims. 3. For health care operations. I can disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. I may also provide your PHI to our accountants, attorneys, consultants, and others to make sure I m complying with applicable laws. 4. Other disclosures. I may also disclose your PHI to others without your consent in certain situations. For example, your consent isn't required if you need emergency treatment, as long as I try to get your consent after treatment is rendered, or if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so. B. Certain Uses and Disclosures Do Not Require Your Consent. I can use and disclose your PHI without your consent or authorization for the following reasons: 1. When disclosure is required by federal, state or Iocal law; judicial or administrative proceedings; or, law enforcement. For example, I may make a disclosure to applicable officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding. 2. For public health activities. For example, I may have to report information about you to the county coroner. 3. For health oversight activities. For example, I may have to provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization. 4. For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research. 5. To avoid harm. In order to avoid a serious threat to the PHI to law enforcement personnel or persons able to prevent or lessen such harm. 6. For specific government functions. I may disclose PHI of military personnel and veterans in certain situations. And I may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations. 7. For workers' compensation purposes. I may provide PHI in order to comply with workers' compensation laws. 8. Appointment reminders and health related benefits or services. I may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits I offer. C. Certain Uses and Disclosures Require You to Have the Opportunity to Object. 1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations. D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in sections III A, B, and C above, I will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I haven't taken any action in reliance on such authorization) of your PHI by me. IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI You have the following rights with respect to your PHI: A. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that I limit how I use and disclose your PHI. I will consider your request, but I am not legally required to accept it. If I accept

14 your request, I will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that I am legally required or allowed to make. B. The Right to Choose How I Send PHI to You. You have the right to ask that I send information to you to at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, instead of regular mail) I must agree to your request so long as I can easily provide the PHI to you in the format you requested.

15 C. The Right to See and Get Copies of Your PHI. In most cases, you have the right to look at or get copies of your PHI that I have, but you must make the request in writing. If I don't have your PHI but I know who does, I will tell you how to get it. I will respond to you within 30 days of receiving your written request. In certain situations, I may deny your request. If I do, I will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed. If you request copies of your PHI, I will charge you not more than $.25 for each page. Instead of providing the PHI you requested, I may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance. D. The Right to Get a List of the Disclosures I Have Made. You have the right to get a list of instances in which I have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or health care operations, directly to you, or to your family. The list also won't include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request. E. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. I will respond within 60 days of receiving your request to correct or update your PHI. I may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by me, (iii) not allowed to be disclosed, or (iv) not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don't file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If I approve your request, I will make the change to your PHI, tell you that I have done it, and tell others that need to know about the change to your PHI. F. The Right to Get This Notice by . You have the right to get a copy of this notice by . Even if you have agreed to receive notice via , you also have the right to request a paper copy of it. V. HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES If you think that I may have violated your privacy rights, or you disagree with a decision I made about access to your PHI, you may file a complaint with the person listed in Section VI below. You also may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C I will take no retaliatory action against you if you file a complaint about my privacy practices. VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT MY PRIVACY PRACTICES If you have any questions about this notice or any com-plaints about my privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me at: 865 Third Street, Suite 204, Santa Rosa, CA 95404, (707) , or jeannevattuone@yahoo.com. VII. EFFECTIVE DATE OF THIS NOTICE This notice went into effect on August 1, 2008.

16 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing this form, you acknowledge receipt of the Notice of Privacy Practices that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your protected health information. I encourage you to read it in full. My Notice of Privacy Practices is subject to change. If I change my notice, you may obtain a copy of the revised notice from me by contacting me at (707) or checking my website If you have any questions about my Notice of Privacy Practices, please contact me at: Sierra Dator, LCSW 204 G Street Suite 204 Petaluma, CA I acknowledge receipt of the Notice of Privacy Practices of Sierra Dator, LCSW. Signature of Client/Guardian Date INABILITY TO OBTAIN ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I made good faith attempts to obtain my patients acknowledgement of his or her receipt of my Notice of Privacy Practices, including. However, because of I was unable to obtain my patient s acknowledgement. Signature of Sierra Dator, LCSW LCS23317 Date

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