CONSENT FOR TREATMENT AGREEMENT



ASCENSIONS PSYCHOLOGICAL & COMMUNITY SERVICES, INC.DEMOGRAPHIC INFORMATIONCLIENT INFORMATIONLAST_______________________________ FIRST____________________ MI_____ADDRESS_____________________________________________________________CITY__________________________________ STATE_____ ZIP_______________PHONE NUMBERS______________________________________________________EMAIL ADDRESS_______________________________________________________DATE OF BIRTH________DATE OF INITIAL CONSULTATION__________SOURCE OF REFERRAL_______________________________________________NAME OF GUARDIAN (if client is a minor)_________________________________INSURANCE INFORMATIONNAME OF INSURANCE COMPANY_____________________________________POLICY #_____________________________________________________________EMPLOYER/GROUP____________________________________________________PERSONS COVERED____________________________________________________POLICY HOLDER/RELATIONSHIP_______________________________________CO-PAY $____________EMPLOYMENT/SCHOOL INFORMATIONNAME_________________________________________________________________ADDRESS______________________________________________________________PHONE #______________________________________________________________EMERGENCY CONTACT INFORMATIONNAME_________________________RELATIONSHIP_________________________ADDRESS______________________________________________________________PHONE #______________________________Please check where you may be reached by phone. Include phone numbers that we can identify ourselves as “doctors’ office.”___Home Phone Number________________________ ___CellPhone Number___________________________WorkPhone Number___________________________OtherPhone Number_________________________CONSENT FOR TREATMENT AGREEMENTAscensions Psychological and Community Services, Inc. Please read and initial beside each section indicating that you are aware and understand the polices of our office. If there is something that you do not understand, please ask for assistance. Evaluation and Diagnostic ProceduresInitialsa. 2 – 4 Sessions________b. Evaluation may consist of diagnosis, interviews with significant others (with your permission), psychological test and measures, and/or referral to other specialists.________c. Treatment will consist of individual/family psychotherapy – frequently determined by the diagnosis and need. Usually once a week, but may vary up or down.________d. Treatment may also consist of a psychiatric referral. ________e. If I believe I am in crisis, I will contact my therapist. I understand that if my therapist is unavailable, I can contact her/his colleague or if necessary, go to the nearest emergency room.________f. Limits of Confidentiality:If a judicial system requests records, depending on the circumstances, the office may have to provide the records.________The office will not release any information without myknowledge and consent. ________If I am a danger to myself or others, my therapist will dowhatever is ethical to protect others and/or myself which may include possible hospital admission, notification of relatives or significant others. I also understand that my therapist hasa duty to warn in DC.________Scheduling, Fees, Missed AppointmentsPayment is expected at the time services are rendered and paidbefore my sessions begin, unless other arrangements have been made.________ I am responsible and not my insurance company for co-payments,co-insurance and deductibles.________There is a charge of $25.00 for missed appointments unless a 24-hour notification is given. Payment is expected at my nextscheduled appointment. ________Because the focus of Ascensions is on therapeutic matters, it is our policy to have no court involvement unless subpoenaed. In this case our hourly rate is $100 for preparation and the court appearance(s)._________Unless prior arrangements are made, our standard rate for reportwriting or completion of paperwork is $100 per page._________ Reasons for Terminationa. If I fail to maintain my agreed financial responsibility._________b. If I miss four scheduled appointments without 24-hour notification.________Group Psychotherapy (if applicable) a. I will keep information revealed by self and others confidential.________b. If I become aware of or have problems with confidentiality or lack of, I will notify my therapist immediately.________All information is confidential with the following exceptions: minors, court ordered patients, and those who pose a risk of danger to themselves or others. Insurance companies or other agents paying for treatment may also receive information as requested. In addition, clinical information may be shared with other professionals for the purpose of coordination of care. I have received an electronic copy of the Psychotherapist-Patient Services Agreement that explains these policies in more detail. _____________________________________________________________ Patient / Parent / Legal Guardian’s SignatureDate_____________________________________________________________ Clinician’s SignatureDatePersonal History for Children and Adolescents (< 18)Client’s name: ___________________________________Date: Gender: ____F ____ M?Date of birth: __________?Age: _______?Grade in school: Form completed by (if someone other than client): Address: _____________________ City: ________________?State: __________?Zip: Phone (home): ____________________?(work): _____________________?Ext: If you need any more space for any of the following questions please use the back of the sheet.Primary reason(s) for seeking services:____ Anger management____ Anxiety____ Coping____ Depression____ Eating disorder____ Fear/phobias____ Mental confusion____?Sexual concerns____ Sleeping problems____ Addictive behaviors____ Alcohol/drugs____ Hyperactivity____ Other mental health concerns (specify): ______________________________________________Family HistoryParentsWith whom does the child live at this time? Are parent’s divorced or separated? ?If Yes, who has legal custody? Where the child’s parents ever married? ____ Yes?____ NoIs there any significant information about the parents’ relationship or treatment toward the child which might be beneficial in counseling? ____ Yes?____ NoIf Yes, describe: Client’s MotherName: _____________?Age: __________?Occupation: ______________________?____ FT?____ PTWhere employed: ______________________________?Work phone: Mother’s education: Is the child currently living with mother? ____ Yes?____ No___ Natural parent ___ Stepparent ___ Adoptive parent ___ Foster home ___ Other (specify): _______Is there anything notable, unusual or stressful about the child’s relationship with the mother?____ Yes?____ No??If Yes, please explain : __________________________________________________________________________________________________________________________________How is the child disciplined by the mother? For what reasons is the child disciplined by the mother? Client’s FatherName: __________________?Age: __________?Occupation: ___________________?___ FT?___ PTWhere employed: _________________________________?Work phone: Father’s education: Is the child currently living with father? ____ Yes?____ No___ Natural parent ___ Stepparent ___ Adoptive parent ___ Foster home ___ Other (specify): _______If there anything notable, unusual or stressful about the child’s relationship with the father?____ Yes?____ No??If Yes, please explain: How is the child disciplined by the father? For what reasons is the child disciplined by the father? Client’s Siblings and Others Who Live in the HouseholdQuality of relationshipName of SiblingsAgeGenderLives???????with the client___________________?___?___ F?___ M?___ home?___ away?___ poor?___ average?___ good___________________?___?___ F?___ M?___ home?___ away?___ poor?___ average?___ good___________________?___?___ F?___ M?___ home?___ away?___ poor?___ average?___ good___________________?___?___ F?___ M?___ home?___ away?___ poor?___ average?___ goodOthers living inRelationshipthe household(e.g., cousin, foster child)______________?___?___ F?___ M?______________________?___ poor?___ average?___ good______________?___?___ F?___ M?______________________?___ poor?___ average?___ good______________?___?___ F?___ M?______________________?___ poor?___ average?___ good______________?___?___ F?___ M?______________________?___ poor?___ average?___ goodComments: Family Health HistoryHave any of the following diseases occurred among the child’s blood relatives? (parents, siblings, aunts, uncles, or grandparents) Check those which apply:____ Allergies____ Deafness____ Muscular dystrophy____ Anemia____ Diabetes____ Nervousness____ Asthma____ Glandular problems____ Perceptual motor disorder____ Bleeding tendency____ Heart diseases____ Mental retardation____ Blindness____ High blood pressure____ Seizures____ Cancer____ Kidney disease____ Spina bifida____ Cerebral palsy____ Mental illness____ Suicide____ Cleft lips____ Migraines____ Other (specify): ____ Cleft palate____ Multiple sclerosis____ Comments re: Family Health:Childhood/Adolescent HistoryPregnancy/BirthHas the child’s mother had any occurrences of miscarriages or stillbirths? ___ Yes?___ NoIf Yes, describe: Was the pregnancy with child planned? ___ Yes?___ No Length of pregnancy: Mother’s age at child’s birth:______Father’s age at child’s birth: ______Child number ___ of ___ total children.How many pounds did the mother gain during the pregnancy? ________While pregnant did the mother smoke? ___ Yes?___ NoIf Yes, what amount: Did the mother use drugs of alcohol? ___Yes?___ NoIf Yes, type/amount: While pregnant, did the mother have any medical or emotional difficulties? (e.g., surgery, hypertension, medication) ___ Yes?___ NoIf Yes, describe: Length of labor: ________???Induced: ___ Yes?___ No??Caesarean? ___ Yes?_____ NoBaby’s birth weight: _______________Baby’s birth length: Describe any physical or emotional complications with the delivery: ___________________________________________________________________________________Describe any complications for the mother or the baby after the birth: ___________________________________________________________________________________Length of hospitalization: Mother: __________________??Baby :_________________________Infancy/Toddlerhood Check all which apply:___ Breast fed___ Milk allergies ___ Vomiting___ Diarrhea___ Bottle fed___ Rashes___ Colic ___ Constipation___ Not cuddly?___ Cried often___ Rarely cried ___ Overactive___ Resisted solid food ___ Trouble sleeping___ Irritable when awakened___ LethargicDevelopmental History Please note the age at which the following behaviors took place:Sat alone: __________________________Dressed self: Took 1st steps: _____________________Tied shoelaces: Spoke words: _______________________Rode two-wheel bike: Spoke sentences: ___________________Toilet trained: Weaned: ___________________________Dry during day: Fed self: ___________________________Dry during night: Compared with others in the family, child’s development was: ?_____ slow?______ average?_____ fastAge for following developments (fill in where applicable)Began puberty: ________________________Menstruation: Voice change: _________________________Convulsions:??Breast development: ___________________Injuries or hospitalization: ?Issues that affected child’s development (e.g., physical/sexual abuse, inadequate nutrition, neglect, etc.) EducationCurrent school: _____________________School phone number: Type of school: ___ Public?___ Private?___ Home schooled?___ Other (specify): ?Grade: ______________??Teacher: ________________School Counselor:In special education? ___ Yes?___NoIf Yes, describe: In gifted program? ___ Yes?___ NoIf Yes, describe: Has child ever been held back in school? ___ Yes?___ NoIf Yes, describe: Which subjects does the child enjoy in school? Which subjects does the child dislike in school??? What grades does the child usually receive in school? ?Have there been any recent changes in the child’s grades? ____ Yes?____ NoIf Yes, describe:?Has the child been tested psychologically? ___ Yes?___ NoIf Yes, describe: Check the descriptions that specifically relate to your child.Feelings about Schoolwork:___ Anxious___ Passive___ Enthusiastic___ Fearful___ Eager___ No expression___ Bored___ Rebellious___ Other (describe):? Approach to Schoolwork:___ Organized ___ Industrious___ Responsible___ Interested___ Self-directed___ No initiative___ Refuses___ Does only what is expected___ Sloppy___ Disorganized___ Cooperative___ Doesn’t complete assignments___ Other (describe):? Performance in School (Parent’s Opinion):___ Satisfactory___ Underachiever___ Overachiever___ Other (describe): Child’s Peer Relationships:___ Spontaneous___ Follower___ Leader___ Difficulty making friends___ Makes friends easily ___ Longtime friends___ Shares easily___ Other (describe): Who handles responsibility for your child in the following areas??School: ___ Mother___ Father___ Shared ___ Other (specify): _____________?Health:___ Mother___ Father___ Shared ___ Other (specify): _____________?Problem behavior:___ Mother___ Father___ Shared ___ Other (specify): _____________If the child is involved in a vocational program or works a job, please fill in the following:What is the child’s attitude toward work? ___ Poor?___ Average?___ Good?___ ExcellentCurrent employer: ___________________________?Position: _____________?Hours per week: _______How have the child’s grades in school been affected since working? ___ Lower ___ Same _____ HigherHow many previous jobs or placements has the child had? ?Usual length of employment: _________________ Usual reason for leaving: Leisure/RecreationalDescribe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, school activities, scouts, etc.) Activity????????????How often now??????? ?How often in the past?__________________________???_______________________???___________________________________________________???_______________________???___________________________________________________???_______________________???___________________________________________________???_______________________???_________________________Medical/Physical Health___ Abortion___ Hay fever___ Pneumonia___ Asthma___ Heart trouble___ Polio___ Blackouts___ Hepatitis___ Pregnancy___ Bronchitis___ Hives___ Rheumatic fever___ Cerebral palsy___ Influenza___ Scarlet fever___ Chicken pox___ Lead poisoning___ Seizures___ Congenital problems___ Measles___ Severe colds___ Croup___ Meningitis___ Severe head injury___ Diabetes___ Miscarriage___ Sexually transmitted disease___ Diphtheria___ Multiple sclerosis___ Thyroid disorders___ Dizziness___ Mumps___ Vision problems___ Earaches___ Muscular dystrophy___ Wearing glasses___ Ear infections___ Nosebleeds___ Whooping cough___ Eczema___ Other skin rashes___ Other___ Encephalitis___ Paralysis_____________________ Fevers___ PleurisyList any current health concerns: List any recent health or physical changes: ___________________________________________________________________________________NutritionMealHow often Typical foods eatenTypical amount eaten (times per week)Breakfast___ / week_______________________ No___ Low___ Med___ HighLunch ___ / week_______________________ No___ Low___ Med___ HighDinner ___ / week_______________________ No___ Low___ Med___ HighSnacks ___ / week_______________________ No___ Low___ Med___ HighComments: Most recent examinationsType of examinationDate of most recent visitResults____Physical examination________________________________________________Dental examination________________________________________________Vision examination________________________________________________Hearing examination________________________________________________Current prescribed medications Dose Dates Purpose Side effects_________________________??________?_____________?_____________?__________________________________________??________?_____________?_____________?__________________________________________??________?_____________?_____________?__________________________________________??________?_____________?_____________?_________________Current over-the-counter meds Dose Dates Purpose Side effects_________________________??________?_____________?_____________?__________________________________________??________?_____________?_____________?__________________________________________??________?_____________?_____________?__________________________________________??________?_____________?_____________?_________________Immunization record (check immunizations the child/adolescent has received):DPTPolio2 months______15 months ___ MMR (Measles, Mumps, Rubella)4 months______24 months ___ HBPV (Hib)6 months______Prior to school ___ HepB18 months______4-5 years______Chemical Use HistoryDoes the child/adolescent use or have a problem with alcohol or drugs? ___ Yes?___ NoIf Yes, describe: _________________________________________________________________________________________________________________________________________________________________________Counseling/Prior Treatment HistoryInformation about child/adolescent (past and present):YesNoWhenWhereReaction oroverall experienceCounselling/Psychiatric__________________________________________treatmentSuicidal thoughts/attempts__________________________________________Drug/alcohol treatment__________________________________________Hospitalizations__________________________________________Behavioral/EmotionalPlease check any of the following that are typical for your child:___ Affectionate___ Frustrated easily___ Sad___ Aggressive___ Gambling___ Selfish___ Alcohol problems___ Generous___ Separation anxiety___ Angry___ Hallucinations___ Sets fires___ Anxiety___ Head banging___ Sexual addiction___ Attachment to dolls___ Heart problems___ Sexual acting out___ Avoids adults___ Hopelessness___ Shares___ Bedwetting___ Hurts animals___ Sick often___ Blinking, jerking___ Imaginary friends___ Short attention span___ Bizarre behavior___ Impulsive___ Shy, timid___ Bullies, threatens___ Irritable___ Sleeping problems___ Careless, reckless___ Lazy___ Slow moving___ Chest pains___ Learning problems___ Soiling___ Clumsy___ Lies frequently___ Speech problems___ Confident___ Listens to reason___ Steals___ Cooperative___ Loner___ Stomachaches___ Cyber addiction___ Low self-esteem___ Suicidal threats___ Defiant___ Messy___ Suicidal attempts___ Depression___ Moody___ Talks back___ Destructive___ Nightmares___ Teeth grinding___ Difficulty speaking___ Obedient___ Thumb sucking___ Dizziness___ Often sick___ Tics or twitching___ Drug dependence___ Oppositional___ Unsafe behaviors___ Eating disorder___ Overactive___ Unusual thinking___ Enthusiastic___ Overweight___ Weight loss___ Excessive masturbation___ Panic attacks___ Withdrawn___ Expects failure___ Phobias___ Worries excessively___ Fatigue___ Poor appetite___ Other:___ Fearful___ Psychiatric problems________________________ Frequent injuries___ Quarrels_____________________Please describe any of the above (or other) concerns:How are problem behaviors generally handled? What are the family’s favorite activities?What does the child/adolescent do with unstructured time?? Has the child/adolescent experienced death? (friends, family pets, other) ___ Yes?___ NoAt what age? ___If Yes, describe the child’s/adolescent’s reaction: Have there been any other significant changes or events in your child’s life? (family, moving, fire, etc.) ___ Yes?___ NoIf Yes, describe:? ___Any additional information that you believe would assist us in understanding your child/adolescent?Any additional information that would assist us in understanding current concerns or problems?What are your goals for the child’s therapy?What family involvement would you like to see in the therapy?Do you believe the child is suicidal at this time? ___ Yes?___ NoIf Yes, explain:?For Staff UseTherapist’s comments: Therapist’s signature/credentials: __________________________________ Date: ___/___/______Supervisor’s comments: ? Physical exam: ___ Required?___ Not requiredSupervisor’s signature/credentials: _________________________________Date: ___/___/______(Certifies case assignment, level of care and need for exam) ................
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