CLINICAL INTERVIEW FORM

Transcription

1 Educatinal Assessment and Student Supprt Clinic 1705 E. Campus Center Drive Rms Salt Lake City, UT Phne: Fax: CLINICAL INTERVIEW FORM Fr Children: Client s Name Date Persn Cmpleting Frm (if ther than Client) Please send all mail crrespndence t: ATTN: Department f Educatinal Psychlgy 1721 E. Campus Center Drive SAEC 3220 Salt Lake City, UT 84112

2 Client Infrmatin Frm Child/Adlescent: Name Date f Birth Educatinal Assessment and Student Supprt Clinic Date Referred by Mther (r guardian): Father (r guardian): Name Name Street Address Street Address City City State Zip State Zip Hme Phne Hme Phne Cell/Wrk Phne Cell/Wrk Phne Date f Birth Date f Birth Marital Status Marital Status Educatin Educatin Occupatin Occupatin Emplyer Emplyer Members f husehld: Name Age Sex Relatinship Name Age Sex Relatinship Name Age Sex Relatinship Name Age Sex Relatinship Ethnicity: (check all that apply) _Caucasian _Hispanic/Latin(a) African American Native American _Asian Other Is the child currently taking medicatin? Drug Dse Purpse Prescribed by Drug Dse Purpse Prescribed by Reasn fr currently seeking services: Previus therapy/evaluatin: Yes/N (if yes, where/when?) 2

3 Clinic Services: The Educatinal Assessment and Student Supprt Clinic f the Department f Educatinal Psychlgy at the University f Utah serves children, adlescents, and adults and their families. The Clinic wrks with schls and ther agencies such as Primary Children s Medical Center t prvide psychlgical, neurpsychlgical, and psycheducatinal assessment, cnsultatin, and interventin in the cmmunity by graduate students and University faculty. The Clinic ffers specialized assessment in specific areas, such as neurpsychlgical assessment f children, adlescents, and adults with learning disabilities, head trauma, attentindeficit/hyperactivity disrder (ADHD), and autism. Psychlgical assessment f children and adlescents with md and behavir disrders is als ffered. Interventins available include individual therapy with children and adlescents; parent training; grup and individual scial skills training; and academic planning and cnsultatin with the schls regarding a student s educatinal plan. The fllwing faculty hld clinic psitins: Janiece Pmpa, Ph. D., Clinic Directr Elaine Clark, Ph. D., Department Chair William Jensn, Ph. D., Supervisr Daniel Olympia, Ph. D., Supervisr Alicia Herner, Ph. D., Supervisr Clinical Interview Frm: Please cmplete this frm prir t yur appintment. Althugh it is lengthy, it is imprtant t btain a clear and accurate develpmental histry f each client in rder t understand his r her learning ability and behavir. It will als help us in frmulating a remediatin plan fr him r her. *(Clients wh have cmpleted the intake packet fr the Neurbehaviral Clinic at Primary Children s Medical Center may substitute that questinnaire fr this ne. Please prvide a cpy t the clinician prir t yu appintment.) In additin, it is very helpful t bring the fllwing t yur appintment: - Medical recrds f treatment and dctr s visits with regard t illness/injury. Especially imprtant are reprts frm neurlgists and neursurgens; reprts f CT/MRI/EEGs f the brain; emergency rm/emt reprts; highway patrl /plice reprts (if there was an accident). - Schl grade reprt cards, transcripts, including results f standardized testing (SAT, CAT, Iwa tests, etc.) - Reprts f previus psychlgical/neurpsychlgical evaluatin (including IQ r academic testing administered by the schl r ther agencies). Please d nt frget t bring these materials and yur cmpleted frm t yur first appintment. 3

4 Referral Questins: Describe the reasns fr referral. Please include specific behavirs r prblems that yu wuld like help with. What services r interventins have been previusly perfrmed (if any)? 4

5 Family Histry: Please indicate any family members n either side wh have had any f the fllwing: MEDICAL PROBLEMS MOTHER S SIDE FATHER S SIDE Intellectual disability Learning disabilities/prblems Hyperactivity/attentin prblems Speech/language prblems Seizures Headaches Genetic disrders Miscarriages Multiple Sclersis Turette s syndrme Thyrid prblems Other medical prblems PSYCHIATRIC PROBLEMS MOTHER S SIDE FATHER S SIDE Depressin/suicide Biplar disrder (Manic-Depressin) Anxiety disrder Panic attacks Obsessive-cmpulsive disrder Phbias and fears Autism spectrum disrder Schizphrenia Hallucinatins Alchl/drug abuse (specify) Nervus breakdwns Other 5

6 Pregnancy, Delivery and Birth: During pregnancy, mther (check all that apply and describe) Drank alchl r used drugs Smked Suffered any illness, infectin, trauma, fevers Had txemia Experienced vaginal bleeding r sptting Almst miscarried Tk medicatin (which?) Had ther significant events ccur During labr and delivery, mther and/r baby (check all that apply and describe) Went int early labr Suffered fetal distress Had induced labr Suffered cmplicatins (breach birth, crd arund neck, lack f xygen, C-sectin, frceps, required xygen, etc.) Required special care (ICU, incubatr, etc.) Length f pregnancy weeks Baby s APGAR scre: Baby s weight lbs z Baby s length After birth did the baby have prblems with Breathing 6

7 Jaundice Sucking r feeding Fd, milk, r ther allergies Other prblems Describe the child s persnality, md, and temperament as an infant and tddler: Develpmental Histry: At what age did the child: Crawl: Sit up: Walk alne: Say first wrd: Please indicate if the child suffered any f these prblems as an infant r yung child and describe: Delayed develpment r grwth Ear infectins, tube placement Head banging Repetitive r unusual mvements Restlessness r veractivity Attentin prblems Aggressin (hitting, biting, kicking) Difficulty making r keeping friends Shunned by peers Defiance, resistance t authrity Describe the child s current friendships: What type f discipline is used with the child? Is it effective? 7

8 What types f rewards r incentives are used with the child? Are they effective? Schl Histry: Child began schl at age. Describe the child s preschl/kindergarten experience: Describe the child s grades and behavir in elementary schl: Describe the child s grades and behavir in junir high schl: Describe the child s grades and behavir in high schl: Medical Histry: When the child was last tested fr: Visin Des the child wear/need glasses r cntacts? Hearing Des the child wear/need hearing aids? List any medicatins prescribed fr the child, dsages and reasn fr the medicatin: Medicatin Dsage Reasn Please indicate and describe the child s current and past health prblems: Age and duratin Treatment Headaches Seizures Head injury 8

9 Lss f cnsciusness Meningitis Encephalitis Brain tumr Paralysis High fever Fainting spells Cma HIV infectin/aids Near drwning Drug/alchl abuse Psychiatric hspitalizatin Psychlgical cunseling Legal prblems/arrests Other If the child has suffered head injury, please describe the incident: Date f the incident: Did the child suffer lss f cnsciusness? Did the child have amnesia f events befre the incident? Did the child remember the incident itself? Was the child treated by a dctr? Hspitalized? Describe the length and curse f the hspitalizatin: Hw lng? After? 9

10 Indicate the neurdiagnstic prcedures perfrmed: CT r brain scan MRI f brain EEG Lumbar puncture (spinal tap) Other (PET, SPECT, etc.) Physicians(s) currently caring fr the child? Please indicate and describe whether yur child currently r in the past has experienced r cmplained f the symptms listed belw. Please indicate whether the prblem has been reslved r is nging. Physical Symptms: Sensitivity t nise Sensitivity t light Ringing in the ears Dizziness Nausea/vmiting Blurred visin Duble visin Hearing prblems Prblems with taste r smell Numbness r tingling in extremities Sleep prblems Fatigue Psychlgical Symptms: Depressin Md swings Irritability Anger 10

11 Aggressin Lw frustratin tlerance Can t handle stress Anxiety Panic attacks Parania Hate t be in crwds Scial withdrawal/scial prblems Hallucinatins Persnality change Difficulty with change Cgnitive Symptms: Memry Pr shrt-term memry Pr lng-term memry Reasning Reasning prblems Take things t literally Difficulty understanding cnsequences f actins Language Prblems understanding what thers say Say what a lt Need frequent repetitin t understand D nt listen Can t fllw a 3-step cmmand Truble expressing self verbally Talk t much r t little Prblems finding the right wrd t say Stutter 11

12 Visuspatial Truble with visual tasks (e.g., puzzles, games, etc.) Pr drawing ability Pr penmanship Get lst frequently Have truble with directins Other Attentin prblems N cncept f time Clumsy, pr mtr skills Drp in schl perfrmance (which subjects and when?) Strengths/Interests: Please describe the child s strengths: Please describe the child s interests: Additinal infrmatin: Please prvide any ther infrmatin r describe any ther cncerns that have nt been cvered in this questinnaire. 12

13 Educatinal Assessment and Student Supprt Clinic Videtape Agreement Name f Child/Adlescent Name(s) f Parent/Guardian I,, as guardian f, authrize permissin t the University f Utah Educatinal Assessment and Student Supprt Clinic (EASSC) t videtape my child fr the purpse f prfessinal educatin, supervisin, treatment and research as part f the service agreement. The vide agreement states: 1. The client cnsents t the use f videtape t be taken in the ffice f the EASSC during the curse f individual treatment. 2. The videtape will be used slely in the interest f the advancement f mental health prgrams and services fr the purpse f prfessinal educatin, supervisin, treatment and research. The videtape will nt be used fr any ther purpse. 3. EASSC agrees nt t use, r permit the use f the name f the child/adlescent named abve in cnnectin with any direct r indirect use f exhibitin f the videtape fr any use ther than set frth in the service agreement. 4. EASSC is the sle wner f all rights in and t the videtape. 5. There shall be n financial cmpensatin fr the use f such videtape. Parent/Guardian signature Date Clinician signature Supervisr signature 13

14 Psychlgical Services psychtherapy/interventins Psychlgical interventins, including psychtherapy, are nt easy t describe in a few general statements. Effective treatment depends upn the particular prblems yu may be experiencing, as well as persnality factrs and establishing a gd therapist-client alliance. In an imprtant respect, psychtherapy is dissimilar t visiting a physician in that it calls fr mre active effrt n yur part. Fr therapy t be mst successful, yu will have t wrk n the things we talk abut during the sessins and at hme. Psychlgical treatment includes ptential fr sme risk as well as benefits. Since therapy may invlve discussing unpleasant aspects f yur life, yu may experience uncmfrtable feelings that may be temprarily discmfrting. On the ther hand, psychlgical treatment has been knwn t prduce many benefits such as a reductin in distress, slutins t specific prblems, and better relatinships. There can be n guarantees f what yu will experience. The University f Utah Educatinal Assessment and Student Supprt Clinic attempts t minimize risks by prviding well-supervised and trained therapists and by cnducting frequent evaluatins f client prgress/status. The first few sessins will invlve an evaluatin f yur needs. By the end f this evaluatin perid, yur therapist will be able t ffer yu an initial impressin f yur needs and a plan fr what treatment might include, if yu decide t cntinue with therapy. If yu ever have any questins abut prcedures, yu shuld discuss them whenever they arise. The University f Utah Educatinal Assessment and Student Supprt Clinic hurs are by arrangement. The clinic des nt prvide full-time telephne cverage during wrking hurs, and yu may be asked t leave a message fr the therapist. Yur therapist will make every effrt t return yur call as sn as pssible. If yu are difficult t reach, please leave sme times yu may be available r an alternative phne number which yu can be reached. The clinic des nt prvide emergency services (see Emergency Care and Crisis Situatins). Psychlgical Services psychlgical/neurpsychlgical/psycheducatinal evaluatins. Evaluatins are designed t prvide benefits such as an accurate descriptin f client, cgnitive, intellectual and psychlgical strengths and weaknesses, treatment planning, schl and vcatinal planning. Hwever, as with psychtherapy, evaluatins include ptential risks as well as benefits, as previusly described. Evaluatins may invlve several appintments f several hurs each, and generally cnsist f interviews with the client, administratin f tests and/r questinnaires, and, when indicated, interviews with schl persnnel, physicians r ther individuals wh can prvide helpful infrmatin t aid in the evaluatin. Yur written cnsent will be necessary t authrize these cntacts. Fllwing the cmpletin f the evaluatin, a sessin will be held with yu and yur clinician t discuss the results. Due t supervisin requirements, it may take several weeks fr yur clinician t prduce a written reprt f the evaluatin. If a reprt must be written by a certain date, please discuss this with yur clinician well in advance. Every effrt will be made t make sure that reprts are written and disseminated in a timely manner. 14

15 Cnfidentiality Utah law prtects the privacy f cmmunicatins between a client and a psychlgist. Every effrt will be made t keep yur evaluatin and treatment strictly cnfidential. In mst situatins, the clinic will nly release infrmatin abut yu/yur child s treatment t thers if yu sign a written authrizatin frm that meets certain legal requirements. In the fllwing situatins, n authrizatin is required: a) Clinical infrmatin abut yu/yur child s case may be shared within the University f Utah Educatinal Assessment and Student Supprt Clinic by the students enrlled in the clinic practicum and faculty fr educatinal and therapeutic purpses. If clinical staff presents case infrmatin at case cnferences, the infrmatin will be disguised s it will be impssible t link the infrmatin t yu r yur family. b) Persnal infrmatin is als shared fr clinic administrative purpses such as scheduling and quality assurance. Clinic files with redacted patient data may als be available t prgram site visitrs. Data cntained in yur file are available fr archival research (i.e. reviews f recrds t describe clinic referrals, utcmes, and trends) as lng as yur identity cannt be linked t the data used. All staff members have been given training abut prtecting yu/yur child s privacy and have agreed nt t disclse any infrmatin withut authrizatin r apprval f the Clinic Directr in mandated reprting situatins (see Limits f Cnfidentiality). c) On ccasin, yur clinician may find it helpful t cnsult with anther health r mental health prfessinal. During such a cnsultatin, every effrt is made t avid revealing the identity f the client. The ther prfessinal is legally bund t keep the infrmatin cnfidential. If yu dn t bject, it is ur plicy t tell yu abut such cnsultatins nly if it is imprtant t yu/yur child and yur therapist wrking tgether. All cnsultatins are nted in the client s clinic recrd. 15

16 Limits f Cnfidentiality There are unusual situatins where the clinic may be required r permitted t disclse infrmatin withut yur authrizatin. These include: a) If the clinic has knwledge, evidence, r reasnable cncern regarding the abuse r neglect f a child, elderly persn, r disabled persn, it is required t file a reprt with the apprpriate agency. Once such a reprt is filed, we may be required t prvide additinal infrmatin. b) If a client cmmunicates an explicit threat f serius physical harm t a clearly identifiable victim r victims, and has the apparent intent and ability t carry ut such a threat, the clinic may be required t take prtective actins. These actins may include ntifying the ptential victim, cntacting the plice, and/r seeking hspitalizatin fr the client. c) If we believe that there is an imminent risk that a client will physically harm himself r herself, we will als take prtective actins (See Emergency Care and Crisis Situatins). d) Althugh curts have recgnized a therapist-client privilege, there may be circumstances in which a curt wuld rder the clinic t disclse persnal health r treatment infrmatin. We als may be required t prvide infrmatin abut curt-rdered evaluatins r treatments. If yu are invlved in, r cntemplating litigatin, yu shuld cnsult with an attrney t determine whether a curt wuld be likely t rder the clinic t disclse infrmatin. e) The clinic is required t prvide infrmatin requested by a legal guardian f a minr child, including a nn-custdial parent. f) If a gvernment agency is requesting infrmatin fr health versight activities r t prevent terrrism (Patrit Act), the clinic may be required t prvide it. g) If a client files a cmplaint r lawsuit against the clinic r prfessinal staff, the clinic may disclse relevant infrmatin regarding the client in rder t defend itself. If any f these situatins were t arise, the clinic wuld make every effrt t fully discuss it with yu befre taking actin, and wuld limit disclsure t what is necessary. While this written summary f exceptins t cnfidentiality shuld prve helpful in infrming yu abut ptential prblems, it is imprtant that yu discuss any questins yu have with us nw r in the future. The laws gverning cnfidentiality can be quite cmplex. In situatins where specific advice is required, frmal legal advice may be needed. Emergency Care and Crisis Situatins The University f Utah Educatinal Assessment and Student Supprt Clinic is nt able t prvide emergency services r psychiatric medicatins. Individuals, wh because f psychiatric difficulties need substantial case management, nging medicatin adjustments, and/r emergency clinician access, are generally nt apprpriate fr a training clinic. Such clients may be seen at the clinic when their situatin is mre stable. 16

17 University f Utah Educatinal Assessment and Student Supprt Clinic clients wh are experiencing a crisis are encuraged t discuss this with their therapist as sn as pssible s that a crisis plan can be develped. A crisis may be generally defined as a situatin r perid in which the persn s usual cping resurces fail and they experience a state f psychlgical disequilibrium in which they may be at risk fr impulsive r harmful behavir. There are many examples f crisis situatins, which may include: A client wh is struggling with suicidal ideatin, a teenager wh under distress runs away frm hme, a psychtic client wh experiences severe symptms such as hallucinatins r parania because they have discntinued medicatins, and an alchl/drug client wh relapses t uncntrlled drug use with danger f verdse r serius harm. Such clients may r may nt cnstitute an imminent danger t themselves r thers; nevertheless, smetimes a judgment must be made t prtect the client. The plicy f the University f Utah Educatinal Assessment and Student Supprt Clinic t which yu cnsent as a client is t prvide cnservative treatment during a crisis situatin. Yur clinician wuld wrk with yu t establish a plan t restre nrmal functining as sn as pssible. In additin t cping skills and pssible envirnmental changes, this may include cnsultatin with yur physician, r if necessary, a family member r significant thers. If yu are student living in university husing, it may mean letting apprpriate university fficials knw f yur situatin. The clinic may divulge yur client status and the minimal treatment infrmatin necessary t prtect yu during a crisis perid. The need fr such an actin will be discussed with yu until the crisis is ver r yur care has been successfully transferred t anther mental health prvider r treatment prgram. This crisis plicy requires that yu trust in ur prfessinal judgment t balance risks with yur rights t cnfidentiality. The crisis plicy is cnsistent with a training clinic that supervises graduate trainees. The clinic instructs clients wh cannt reach us and are having an emergency t cntact a lcal hspital emergency rm r ther cmmunity resurces directly such as University Neurpsychiatric Institute (801) , r Valley Mental Health (801) Prfessinal Recrds and Client Rights The laws and standards f the psychlgy prfessin require that the clinic keep Prtected Health Infrmatin (PHI) abut yu in yur clinical recrd. Generally, yu may examine and/r receive a cpy f yur clinical recrd, if yu request it in writing. There are a few exceptins t the access: 1) sme unusual circumstances described abve, 2) when the recrd makes reference t anther persn (ther than a health care prvider) and we believe that access is reasnably likely t cause substantial harm t that persn, r 3) where infrmatin has been supplied cnfidentially by thers. Als, the clinic will nt release cpyrighted test infrmatin r raw data t yu r yur representative withut a subpena. Because these are prfessinal recrds, they can be misinterpreted. Fr this reasn, the clinic recmmends that yu initially review them in the presence f yur therapist, r have them frwarded t anther mental health prfessinal s yu can discuss the cntents. The University f Utah Educatinal Assessment and Student Supprt Clinic keeps n additinal ntes (smetimes called psychtherapy r prgress ntes) beynd the clinical recrd. In mst circumstances, the clinic is allwed t charge a cpying fee 17

18 fr reprducing yur recrds. If the clinic refuses yur request fr access t yur recrds, yu have the right t a review f this decisin (except fr infrmatin supplied cnfidentially by thers), which the Clinic Directr will discuss with yu upn request. HIPAA prvides yu with several new r expanded rights with regard t yur clinical recrds and disclsures f prtected health infrmatin. These rights include requesting that the clinic amend yur recrd; requesting restrictins n what infrmatin frm yur clinical recrds is disclsed t thers; requesting an accunting f mst disclsures f prtected health infrmatin that yu have neither cnsented t nr authrized; determining the lcatin t which prtected infrmatin disclsures were sent; having any cmplaints yu make abut clinic plicies and prcedures recrded in yur recrds; and the right t a paper cpy f this Agreement, the attached Ntice frm, and ur privacy plicies and prcedures. Yur therapist r the Clinic Directr will be happy t discuss any f these rights with yu. Research The psychlgy clinic als prvides a site fr clinical research cnducted by graduate students and the clinical faculty. Clients may be apprached fr participatin in clinical research studies cnducted by University f Utah Educatinal Assessment and Student Supprt Clinic and/r their graduate students wh have received prir apprval fr the specific study frm the University f Utah Human Subjects Cmmittee (Institutinal Review Bard). Prir t any research participatin, a separate infrmed cnsent fully explaining the study must be prvided, and the individual can chse either t participate r nt t participate. Any client wh decides nt t participate in a study will nt be penalized (i.e. services t which they are rdinarily entitled thrugh EASSC will nt be withheld if yu chse nt t participate in any research study). Fees, Billing, and Payment Plicy The University f Utah Educatinal Assessment and Student Supprt Clinic charges reduced fees. If yu situatin is apprpriate fr the clinic and yu decide t seek services, yu will be asked t sign a fee cntract with specific fee arrangements. The fee schedule is as fllws: Child Psychlgical/Psycheducatinal evaluatin: $250 Autism/psycheducatinal evaluatin: $350 Neurpsychlgical evaluatin: $500 Psychtherapy/Interventin: $20/hur Payment is due at the time f service. The clinic des nt bill r accept insurance payments. If yu are unable t affrd these fees, yu may petitin the Clinic Directr fr reduced fees r t set up a payment plan. 18

19 Summary f Client Respnsibilities As a client f the University f Utah Educatinal Assessment and Student Supprt Clinic, yu agree t: 1. Keep regular appintments and actively participate in yur treatment. 2. Attempt any therapeutic assignments yu/yur child agree t perfrm. 3. Make a cmmitment t living and using clinic and cmmunity resurces t slve difficulties. Yu/yur child will be asked t agree t disclse t the therapist feelings f being in crisis and/r suicidal, t wrk with the therapist t develp a crisis plan, and t give the clinic discretin regarding needed disclsures in a crisis situatin. 4. Nt t cme t the clinic under the influence f alchl r ther drugs. If yu/yur child appear intxicated, the clinician will cancel the sessin and request that the intxicated persn refrain frm driving. Failure t d s will require a DUI reprt. 5. Never bring a weapn f any srt t the clinic. 6. Ask yur therapist questins right away if yu are uncertain abut yur child s evaluatin, therapeutic prcess r any clinic plicy. 7. Pay agreed-upn evaluatin and treatment fees r make arrangements t d s. 8. If the client is a child, a parent r adult must remain in the waiting rm in case f emergency. Infrmed Cnsent Yur signature belw indicates that yu have read this agreement and agree t its terms. These matters have been explained t yu and yu fully and freely give cnsent fr yur child t receive clinic evaluatin and/r treatment services. Name f Client(s) please print Signature f Client(s) and/r Minr Child Date Signature f Legal Representative f Minr Child Date Witnessed by Date 19

20 Educatinal Assessment and Student Supprt Clinic Ntice f Privacy Practices Brief Versin 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. Our cmmitment t yur privacy: The University f Utah Educatinal Assessment and Student Supprt Clinic is dedicated t maintaining the privacy f yu/yur child s persnal health infrmatin as part f prviding prfessinal care. We are als required by law t keep yu/yur child s infrmatin private. These laws are cmplicated, but we must give yu this imprtant infrmatin. This is a shrter versin f the full, legally required Ntice f Privacy Practices (NPP). Please ask yur clinician if yu wuld like a cpy f NPP fr yur recrds. We will use the infrmatin abut yu/yur child s health which we get frm yu r frm thers mainly t prvide yu/yur child with treatment, t dcument payment fr services, and fr sme ther business activities which are called, in the law, health care peratins. After yu have read this NPP we will ask yu t sign a Cnsent Frm t let us use and share yur infrmatin. Yur signature is necessary fr us t serve yu. If yu r the Clinic want t use r disclse (send, share, release) yu/yur child s infrmatin fr any ther purpses yur clinician will discuss this with yu and ask yu t sign an Authrizatin frm t allw this. We will keep yu/yur child s health infrmatin private but there are sme times when the laws require us t use r share it. Fr example: 1. When there is a serius threat t yur health and safety r the health and safety f anther individual r the public. We will nly share infrmatin with a persn r rganizatin that is able t help prevent r reduce the threat. 2. Sme lawsuits and legal r curt prceedings. 3. If a curt requires us t d s. 4. Fr Wrkers Cmpensatin and similar benefit prgrams. Additinal situatins, which are less cmmn, are described in the lnger versin f NPP. 20

21 Yur rights regarding yur health infrmatin: 1. Yu can ask yur clinician t cmmunicate with yu abut health and related issues in a particular way r at a certain place which is mre private fr yu. Fr example, yu can ask him/her t call yu at hme, and nt at wrk t schedule r cancel an appintment. He/she will try his/her best t accmmdate yur request. 2. Yu have the right t ask yur clinician t limit what he/she tells peple invlved in yu/yur child s care r the payment fr such care, such as family members and friends. While he/she desn t have t agree t yur request, if he/she des agree, he/she will keep this agreement except if it is against the law, r in an emergency, r when the infrmatin is necessary t treat yu. 3. Yu have the right t lk at the health infrmatin we have abut yu/yur child in the rutine case ntes and billing recrds. Yu can get a cpy f these recrds but we may charge yu fr this service. 4. If yu believe the infrmatin in yur recrds is incrrect r missing imprtant infrmatin, yu can ask yur clinician t make sme kinds f changes (called amending) t yu/yur child s health infrmatin. Yu have t make this request in writing and send it t him/her. Yu must tell him/her the reasns yu want t make changes. 5. Yu have the right t a cpy f this ntice. If we change this NPP we will pst the new versin in the waiting area. Yu can request a cpy f the NPP frm yur clinician. 6. Yu have the right t file a cmplaint if yu believe yu/yur child s privacy rights have been vilated. Yu can file a cmplaint with the Clinic Directr, Dr. Janiece Pmpa, and with the Secretary f the Department f Health and Human Services. All cmplaints must be in writing. Filing a cmplaint will nt change the health care yur clinician prvides t yu/yur child in any way. If yu have any questins regarding this ntice r the health infrmatin privacy plicies, please cntact: Dr. Janiece Pmpa janiece.pmpa@utah.edu The effective date f this ntice is September 18, 2008 My clinician has discussed the health infrmatin privacy plicies with me. Signature Date 21

22 Educatinal Assessment and Student Supprt Clinic Client Acknwledgement f Receipt f Ntice f Privacy Practices (Yu may refuse t sign this acknwledgement) I,, have received a cpy f the Ntice f Privacy Practices frm. Name Client Name (if minr) Signature Date Fr Office Use Only We have made a gd faith effrt in attempting t btain written acknwledgement f receipt f the Ntice f Privacy Practices. Acknwledgement culd nt be btained fr the fllwing reasn(s): Patient/Individual refused t sign (Date f refusal) Cmmunicatin barriers prhibited btaining an acknwledgement An emergency situatin prevented us frm btaining an acknwledgement Other An attempt was made by: Explain: Date: 22