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Dr. Tania Glenn & Associates, PA

9111 Jollyville Rd, Ste 210

Austin, TX 78759

512-323-6994

512-323-9490 (fax)

Parenting Assessment Packet

Please complete this packet if you are a new patient and bring it with you to your first appointment with the therapist

Thank you

Demographic Information

Dr. Tania Glenn & Associates, PA

Client’s Name:_____________________________ Date: _______________

Gender: _____M _____F Date of birth: _________ Age: ________

Form completed by (if other than client); __________________________________

Address: ________________________ City: ______________ State: _____ Zip: ____

Phone (home): ____________________ (work): _________________ ext: _________

Mobile: __________________________ Email Address: ___________________________

Social Security Number: ____-_____-_____ Medicaid Number: ___________________

Other Insurance Name: _______________________ ID Number: _________________

Name of Insured: _____________________________ Relationship to you: __________

Emergency Contact Information

Name: _____________________________ Relationship to you: _________________

Phone number(s): ______________________________________________________

Address: ______________________________________________________________

If you need any more space for any of the questions please use the back of the sheet.

Primary reasons for seeking services:

Goals for therapy: _____________________________________________________________________

_______________________________ _______________________________

Signature of Client or Representative Signature of Clinician

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

I understand that Dr. Tania Glenn & Associates, PA is authorized by me to use or disclose my Protected Health Information for a purpose other than for treatment, payment, or health care operations. I have read this authorization and understand what information will be used or disclosed, who may use and disclose the information, and the recipient(s) of that information. I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned upon me signing this authorization.

I specifically authorize Dr. Glenn or her designated employee(s) to disclose my Protected Health Information as described on this form to the recipient listed below. I understand that when the information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by state or federal privacy regulations. I further understand that I retain the right to revoke this authorization, if done so according to the steps set forth below.

Description of the information to be used or disclosed (check all that apply):

❑ My entire mental health record

(Note: This requires an explanation of why it is necessary to disclose the entire record)

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

❑ My demographic information (check all that apply):

[ ] Name [ ] Address [ ] State/Zip Code only [ ] Telephone

[ ] Age [ ] Gender [ ] Race [ ] Other: ______________________________________________________________________________

❑ Mental Health Data/Information as related to:

[ ] Specific condition(s): ______________________________________________________________________________

[ ] Specific professional service(s): ______________________________________________________________________________

[ ] Specific medication(s): ______________________________________________________________________________

[ ] Other: ______________________________________________________________________________

❑ Psychotherapy Notes

❑ Other: ____________________________________________________________________________

Please disclose the above information to:

Name: ____________________________________________ Telephone: ______________________

Address: _____________________________________________________________________________

Purpose(s) for disclosure of the information:

_____________________________________________________________________________________

_____________________________________________________________________________________

(Note: if the client is requesting disclosure, the purpose may simply state: “Client is requesting disclosure.”)

I have a right to revoke this authorization in writing, except to the extent that action has been taken in reliance to this authorization. In order for the revocation to be effective, Dr. Glenn must receive the revocation in writing, and the revocation must include:

• My name, address, and patient number, if applicable.

• The effective date of this authorization, and the recipients of the Protected Health Information according to this authorization.

• My desire to revoke this authorization

• The date of the revocation and my signature

Should I wish to access my Protected Health Information, such request must be made in writing. I also agree that such access may be provided in summary form. I will provide all reasonable copying, postage, and preparation costs.

This authorization shall expire upon disclosure of the information specified to be released in this authorization. After this date, Dr. Glenn can no longer use or disclose my Protected Health Information for the above purposes without first obtaining a new authorization form.

I fully understand and accept the terms of this authorization.

_______________________________________ ________________________________

Signature of Client or Client’s Representative Date

_______________________________________ ________________________________

Name of Client Client Identification Number

_______________________________________________ ________________________________

Name of Representative (if applicable) Description of Representative’s

authority to act for patient

For Office Use Only

[ ] Authorization added to client’s record on _________________

[ ] Client has been provided with a copy of the signed authorization

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

I understand that Dr. Tania Glenn & Associates, PA is authorized by me to use or disclose my Protected Health Information for a purpose other than for treatment, payment, or health care operations. I have read this authorization and understand what information will be used or disclosed, who may use and disclose the information, and the recipient(s) of that information. I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned upon me signing this authorization.

I specifically authorize Dr. Glenn or her designated employee(s) to disclose my Protected Health Information as described on this form to the recipient listed below. I understand that when the information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by state or federal privacy regulations. I further understand that I retain the right to revoke this authorization, if done so according to the steps set forth below.

Description of the information to be used or disclosed (check all that apply):

❑ My entire mental health record

(Note: This requires an explanation of why it is necessary to disclose the entire record)

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

❑ My demographic information (check all that apply):

[ ] Name [ ] Address [ ] State/Zip Code only [ ] Telephone

[ ] Age [ ] Gender [ ] Race [ ] Other: ______________________________________________________________________________

❑ Mental Health Data/Information as related to:

[ ] Specific condition(s): ______________________________________________________________________________

[ ] Specific professional service(s): ______________________________________________________________________________

[ ] Specific medication(s): ______________________________________________________________________________

[ ] Other: ______________________________________________________________________________

❑ Psychotherapy Notes

❑ Other: ____________________________________________________________________________

Please disclose the above information to:

Name: ____________________________________________ Telephone: ______________________

Address: _____________________________________________________________________________

Purpose(s) for disclosure of the information:

_____________________________________________________________________________________

_____________________________________________________________________________________

(Note: if the client is requesting disclosure, the purpose may simply state: “Client is requesting disclosure.”)

I have a right to revoke this authorization in writing, except to the extent that action has been taken in reliance to this authorization. In order for the revocation to be effective, Dr. Glenn must receive the revocation in writing, and the revocation must include:

• My name, address, and patient number, if applicable.

• The effective date of this authorization, and the recipients of the Protected Health Information according to this authorization.

• My desire to revoke this authorization

• The date of the revocation and my signature

Should I wish to access my Protected Health Information, such request must be made in writing. I also agree that such access may be provided in summary form. I will provide all reasonable copying, postage, and preparation costs.

This authorization shall expire upon disclosure of the information specified to be released in this authorization. After this date, Dr. Glenn can no longer use or disclose my Protected Health Information for the above purposes without first obtaining a new authorization form.

I fully understand and accept the terms of this authorization.

_______________________________________ ________________________________

Signature of Client or Client’s Representative Date

_______________________________________ ________________________________

Name of Client Client Identification Number

_______________________________________________ ________________________________

Name of Representative (if applicable) Description of Representative’s

authority to act for patient

For Office Use Only

[ ] Authorization added to client’s record on _________________

[ ] Client has been provided with a copy of the signed authorization

Dr. Tania Glenn & Associates, PA

Psychosocial Questionnaire

Name: ____________________________________ Date of Birth: ________________

Caseworker’s Name: ____________________ Caseworker’s Phone: ______________

Please give a summary of your involvement with DFPS. Include all history, current circumstances and status of your case:

Psychosocial Assessment Page 2

Please describe your current feelings about your situation and any other relevant stressors you have in your life right now. Please also give your history of emotional problems, substance abuse and psychiatric treatment. Give dates for hospitalizations, counseling received, detoxification treatment, etc.

Describe your current relationships with family members. Please also list any pertinent history regarding your family (divorces, marriages, violence, etc.).

Please describe your current family functioning. What are the stressors or conflicts? What is going well in your family and what are the challenges? How has your family functioned historically? Is your current family functioning better or worse than it has been?

_____ Married ______ Single ______ Divorced ______ Widowed

Please describe any relevant current health issues and your health history.

Are you currently involved in other legal situations (besides DFPS)? Do you have any other relevant legal history (arrests, lawsuits, etc)? Please describe.

Please describe your education. Last grade completed? Degrees awarded? Please give dates.

Please list your work history and describe your current work situation.

Parent Assessment Clinical Interview Responses:

1. How would you rate yourself as a parent with 1 meaning that you are not even close to being the parent you want to be and 10 meaning that you are doing as well as you would like to be as a parent.

2. What do you feel need to improve on as a parent?

3. Please describe your children, how they act, things they like to do, their accomplishments and things they do well.

4. Who do you feel that your children need to stay connected to?

5. How do you show your children that you love them?

6. What do you do when you are frustrated around her children?

7. How do you discipline your children?

8. Please describe a good memory of your children.

9. What do you feel that your children need most?

10. Do you feel that you will be able to make the necessary changes in her life to be able to parent your children effectively?

Client’s signature: ___________________________________________________

Adult Problem Checklist

Name: __________________________________________ Date: ________________

Person completing this form: ______________________________________________________

A

Please identify your concerns about this adult by placing a number beside a problem, using the choices below. Do not place numbers next to problems about which you have no concerns.

8 = Slight concern but I have not thought about getting help for this problem

7 = Some concern or I have thought about getting help for this problem

6 = Moderate concern or someone has encouraged me to get help for this problem

5 = Serious concern or a few people have encouraged me to get help for this problem

4 = Major concern or many people have pressured me to get help for this problem

3 = Unable to function or I am totally unable to do what is age-appropriate in this area

2 = A danger to self or others some of the time

1 = A persistent danger to self or others

|_____ |Acts without Thinking (Hyperactive or Impulsive) |_____ |Legal Problems |

|_____ |Aggressive Behavior |_____ |Lonely |

|_____ |Alcohol Consumption |_____ |Lying |

|_____ |Anger |_____ |Making or Keeping Friends |

|_____ |Anxious, Tense, Worried |_____ |Marriage |

|_____ |Appetite |_____ |Memory |

|_____ |Arguing |_____ |Mood Swings |

|_____ |Bad Dreams or Nightmares |_____ |Pain |

|_____ |Being Ignored or Abandoned |_____ |Panic |

|_____ |Bothered by Recurring Thoughts |_____ |Parent(Child Relationship |

|_____ |Bothered by a Traumatic Event |_____ |Paying Attention or Concentrating |

|_____ |Bullying or Threatening Others |_____ |Perfectionistic |

|_____ |Career |_____ |Performing Unusual Habits or Rituals |

|_____ |Confused |_____ |Planning or Organizing Work |

|_____ |Critical of Self |_____ |Procrastination |

|_____ |Destruction of Property |_____ |Restless |

|_____ |Eating |_____ |Sadness/Depression |

|_____ |Energy Level |_____ |Satisfaction with Life |

|_____ |Family |_____ |Seeing or Hearing Strange Things |

|_____ |Fears or Phobias |_____ |Self-Injurious Behavior or Suicide |

|_____ |Feeling Detached from Myself |_____ |Sexual Behavior or Responses |

|_____ |Fidgeting, Squirming, "Hyper" |_____ |Shy |

|_____ |Fighting |_____ |Sleeping |

|_____ |Finances |_____ |Social Skills |

|_____ |Grief, Bereavement |_____ |Social Support (Family and Friends) |

|_____ |Guilt or Shame |_____ |Stealing |

|_____ |Health Problems |_____ |Strange, Weird, or Peculiar Behavior |

|_____ |Illegal Drugs or Substances |_____ |Suspicious or Mistrustful |

|_____ |Illegal or Unlawful Behavior |_____ |Thinking about Suicide |

|_____ |Impact of Adult's Problems on Spouse |_____ |Trusting Other People |

|_____ |Impact of Adult's Problems on the Children |_____ |Using Nonprescription Drugs or Substances |

|_____ |Irritable |_____ |Weight |

|_____ |Job/Work Attendance |_____ |Well-Being |

|_____ |Job/Work Performance |_____ |Other: _______________________________________ |

|_____ |Job/Work Satisfaction |_____ |Other: _______________________________________ |

|_____ |Lack of Interest/Enjoyment in Life |_____ |Other: _______________________________________ |

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