MINORINTAKEFORMThetherapyandcounselingworkwedoisuniquetoyou,justasitistoeachoneofourclients.Beforewegetstartedweneedtocollectsomegeneralinformationfromyou.

GENERALINFORMATION

FirstName LastName Gender

DateofBirth(mm/dd/yyyy) SocialSecurityNumber

Nameofpersoncompletingthisform

Relationshiptopatient

Mother’sInformation

FirstName LastName Gender

DateofBirth(mm/dd/yyyy) SocialSecurityNumber

Address

City State ZipCode

MainPhone OtherPhone

Emailaddress

Father’sInformation

FirstName LastName Gender

DateofBirth(mm/dd/yyyy) SocialSecurityNumber

Address

City State ZipCode

MainPhone OtherPhone

Emailaddress

ParentMaritalStatus: ☐Married ☐Divorced ☐Widowed

Whohaslegal/physicalcustody?______________________________________

Pleaseprovidelegaldocumentationifnecessaryfortheinformationabove(custody).

INSURANCEINFORMATION

PRIMARYINSURANCE PolicyHolder

PolicyHolderD.O.B.(mm/dd/yyyy) Relationship

PolicyHolderAddress

City State ZipCode

PolicyNumber GroupNumber

SECONDARYINSURANCE PolicyHolder

PolicyHolderD.O.B.(mm/dd/yyyy) Relationship

PolicyHolderAddress

City State ZipCode

Policy Number Group Number

MENTALHEALTHHISTORY/STATUSWhatareyourconcernsforthisindividual?

Whatareyourexpectationsfortreatmentatthisfacility?

PastMentalHealthTreatment

Hasyourchildeverbeenhospitalizedforpsychiatricreasons? ☐ YES ☐ NO

Ifyes,whenandwhere?

Hasyourchildeverhadoutpatienttreatmentbyapsychiatrist? ☐ YES ☐ NO

Ifyes,whenandbywhom?

Hasyourchildeverreceivedcounselingorpsychotherapyinthepast? ☐ YES ☐ NO

Ifyes,whenandbywhom?

PleaseListanypsychiatricmedicationyourchildhastakenoraretaking:

Medication Date SideEffects/Benefits

Pleasecheckanysymptomsyourchildmaybeexperiencing:

☐ Depression(sad,irritable,hopeless,poorsleep,crying,socialwithdrawal,lackofinterest)

☐ Moodswings(energetic,littlesleep,pleasureseeking,racingthoughts,extremelytalkative,inappropriatesexualbehaviors,grandiose)

☐ Anxiety(worry,restless,scared,poorsleep,obsessivethoughtsand/orcompulsivebehavior)

☐ Behavioralproblems(fights,anger,arguing,truancy,destructionofproperty,firesetting)

☐ Attention/Hyperactivityproblem(difficultywithattention,hyperactive,impulsive,distractibility,notcompletingtasks)

☐ AbnormalEatingBehaviors(toomuch,toolittle,fearofweightgain,distortedbodyimage,overexercising)

☐ Nevertired

☐ RememberingPastTraumas(frequentnightmares,intrusiveand/orrecurringmemories)

☐ Social/languageimpairment(limitedvocabulary,mispronouncingwords,underdevelopmentoflanguageabilityfortheirage)

☐ Psychosis(hearingvoices,seeingthings,paranoia,delusions)

☐ Dissociation(feelingoutsidetheirbodyorthinkingthingsarenotreal)

☐ Harmingthemselvesintentionally

☐ Attemptedsuicide

☐ Harmedothers

DrugandAlcoholHistory

Areyouconcernedaboutyourchildconsumingalcoholorrecreationaldrugs?☐ YES☐ NO

Details:

GENERALMEDICALHISTORY

PrimaryCarePhysician:Pleaselistanymedicalproblemsyourchildmayhavebelow:

Pleaselistanyseriousmedicalproceduresyourchildhashadinthepast:

Isyourchildonanymedicationsforanygeneralmedicalproblemstheymayhave? ☐ YES☐ NO

Ifyes,whichones?

Doesyourchildhaveanyallergiestomedications?☐ YES☐ NO

Ifyes,whichones?

FamilyMedicalHistoryListanyhistoryofillness(mentalorother)andsubstanceabuseamongbloodrelatives:

Mother’sside Father’sside

SOCIALHISTORY

Birthplace: Isthisyourbiologicalchild?

Doesyourchildhavesiblings?☐ YES☐ NO Howmany?____________

Pleaselistyourchild’ssiblings,agesandanyoneelsewhomaybelivinginthehousewithyourchild:

Name Age Relationship

Mother’soccupation:

Father’soccupation:

Hasyourchildeverbeenavictimofabuseorneglect?☐ YES☐ NO

Ifyes,whatisorwasthenatureoftheabuse(checkallthatapply):

☐ Physical ☐ Witnessingviolence

☐ Emotional ☐ Accidents

☐ Neglect ☐ Disasters

☐ Sexual

☐ Other:

Asaparent,areyouexperiencingissueswithmarriageorparenting?☐ YES☐ NO

SCHOOLHISTORY

Wheredoesyourchildgotoschool?

Gradelevel:__________TypicalGrades:___________Whatareyourchild’sacademicstrengths?Whatareasareyouconcernedabout?

Haveyounoticedachangeinyourchild’sperformanceatschool? ☐ YES☐ NODetailsHasyourchildeverparticipatedinanyofthefollowing:

Resource ☐ YES☐ NO

Accelerated/HonorsProgram ☐ YES☐ NO

504Plan ☐ YES☐ NO

IndividualEducationPlan(IEP) ☐ YES☐ NO

Details:Activities/FriendshipsWhatactivitiesdoesyourchildparticipatein/enjoydoing?Howwouldyoudescribeyourchild’ssocialtendencies?

Doyouhaveconcernsregardingyourchild’sfriendship ☐ YES☐ NOExplain

Areyouconcernedaboutyourchild’ssexualactivities? ☐ YES☐ NOExplain

Pleaselistanyadditionalnotesthatyouthinkwouldbehelpfulfortreatmentbelow:

MINORCONSENTTOTREATMENT

FirstName LastName

IgiveHealingMinds,LLCmyconsenttotreatmychild.Ifwearetreatingyourchild,wewilldoourbesttoaccuratelydiagnosethemanddesignacomprehensivetreatmentplanthatwillenableyourchildtocontinuewithanormalemotionaldevelopment.Thismayincluderecommendationsoftherapy,medications,and/orcallingtheschooltotryandhelparrangeyourchildtoreceiveoptimaleducation.Thisisallpartoftheserviceofamentalhealthprofessional.Wewillalsoworkwithhis/herprimarycarephysiciantoassurecoordinationofcare.

_________(Initial)

Itisimportanttonotethatwhenweareseeingyourchild,youconsenttotreatmentforthem.Theyareourclientandhaveconfidentiallyrights.Confidentialitydoesnotapplyundercertainsituations:Weareobligatedbylawtoreportanysuspicionofchildabuse.Thisincludesphysicalorsexualabuse.Also,wehaveadutytoprotectifwesuspectanyoneisindangerofkillingthemselvesorhasmadethreatstohurtsomeoneelse.Exceptintheseraresituations,yourchildhastherighttokeepparticulartopicsconfidentialfromevenhis/herguardian.Pleaserespectthisconfidentiality.Again,ifthereisanyconcernofharm,suicideorotherdangerousbehavior,wewillinformyou.

_________(Initial)

IfIrequireorthinkitisinyouoryourchild’sbestinteresttocommunicatewithanoutsidesource,suchashis/herschool,Iwillrequestareleaseofinformation.Wedonotperformcustodyevaluations.Ifthereisaquestionofcustody,therewillneedtobeaseparate,neutralevaluationthatbothpartiescanagreeon.Toassuregoodtherapeuticcare,frequentappointmentsarerequired.Unlessarrangedotherwise,clientsthathavenotbeenseenin3monthswillbeconsideredinactive.Anewevaluationwillberequiredforanyinactiveclienttobeseen

_________(Initial)

ClientSignature(orRepresentative) Date

SignatureofGuardian/Parent Relationship

LIFETIMEINSURANCEAUTHORIZATIONANDRELEASEOFINFORMATION

FirstName LastName

ReleaseofInformation:I,thesubscribernamedbelow,authorizeHealingMinds,LLCandanyphysiciansworkingunderHealingMinds,LLCexaminingortreatingmetoreleaseanyandallinformationpertainingtomytreatmenttoanythirdpartypayer(suchasmyinsurancecompanyoragovernmentagency)asneededtodetermineaclaimforpaymentforsuchtreatmentandordiagnosis.

PhysicianInsuranceAssignment:I,thebelownamedsubscriber,herbyauthorizepaymentdirectlytoHealingMinds,LLCformytreatmentatthisofficethatisotherwisepayabletomefortheirservicesasdescribed.

Medicare/Medicaid–Client’scertificationauthorizationtoreleaseinformationandpaymentrequest,IcertifythattheinformationgivenbymeinapplyingforpaymentunderTitleXVIII/XIXoftheSocialSecurityActiscorrect.IauthorizeanyholderofmedicalorotherinformationaboutmetobereleasedtoSocialSecurityAdministration/DivisionofFamilyServicesoritsintermediariesorcarriesanyinformationneededforthisofarelatedMedicare/Medicaidclaim.Iherbycertifyallinsurancepertainingtotreatmentshallbeassignedtothephysiciantreatingme.

IPERMITACOPYOFTHESEAUTHORIZATIONSANDASSIGNMENTSTOBEUSEDINPLACEOFTHEORIGINALWHICHISONFILEATTHEPHYSICIAN’SOFFICE.Thisassignmentwillremainineffectuntilrevokedbymewriting.

Pleaserememberthatinsuranceisconsideredamethodofreimbursingtheclientforfeespaidtothedoctorandisnotasubstituteforpayment.Somecompaniespayfixedallowancesforcertainproceduresandotherspayapercentageofthecharge.Iunderstandit’smyresponsibilitytopayanydeductibleamountco-insurance,oranyotherbalancenotpaidforbymyinsuranceorthirdpayerwithinareasonableperiodoftimenottoexceed90days.

ClientName(pleaseprint)

Client/GuardianSignature Date

InsuranceCompany

HIPPANOTICE/PRIVACYPRACTICES

FirstName LastName

Thisnoticedescribeshowmedicalinformationaboutyoumaybeusedanddisclosedandhowyoucangetaccesstothisinformation.Pleasereviewitcarefully.

HealingMinds,LLC6490S.McCarranBlvdA-6,RenoNV,89509,775448-9760

Weunderstandtheimportanceofprivacyandarecommittedtomaintainingtheconfidentialityofyourinformation.Wemakearecordofthemedicalcareweprovideandmayreceivesuchrecordsfromothers.Weusetheserecordstoprovideorenableotherhealthcareproviderstoprovidequalitymedicalcare,toobtainpaymentforservicesprovidedtoyouasallowedbyyourhealthplanandtoenableustomeetourprofessionalandlegalobligationstooperatethismedicalpracticeproperly.Wearerequiredbylawtomaintaintheprivacyofprotectedhealthinformation,toprovideindividualswithnoticeofourlegaldutiesandprivacypracticeswithrespecttoprotectedhealthinformation,andtonotifyaffectedindividualsfollowingabreachofunsecuredprotectedhealthinformation.Thisnoticedescribeshowwemayuseanddiscloseyourmedicalinformation.Italsodescribesyourrightsandourlegalobligationswithrespecttoyourmedicalinformation.Ifyouhaveanyquestionsaboutthisnoticepleasecontactouroffice.

Seefrontofficefor“HIPPADetail”forms.

ClientName(pleaseprint)

Client/GuardianSignature Date

AUTHORIZATIONFORRELEASEOFINFORMATIONFirstName LastName

DateofBirth(mm/dd/yyyy)

WerespectyourpersonalinformationandwantyoutoknowyourrightsasaclientofHealingMinds.Pleasereadtheinformationbelow.

PATIENTRIGHTS

• Youmayendthisauthorization(permissiontouseordiscloseinformation)anytimebycontactingouroffice.

• Ifyoumakearequesttoendthisauthorization,itwillnotincludeinformationthatmayhavealreadybeenusedordisclosedbasedonyourpreviouspermission.

• Youwillnotberequiredtosignthisformasaconditionoftreatment,payment,enrollment,oreligibilityforbenefits.

• Youhavearighttoacopyofthissignedauthorization.

• Ifyouchoosenottoagreewiththisrequest,yourbenefitsorserviceswillnotbeaffected.

PATIENTAUTHORIZATION

Iherebyauthorizethename(s)orentitieswrittenbelowtoreleaseverballyorinwritinginformationregardinganymedical,legal/courtrecords,educationalrecords,mentalhealthand/oralcohol/drugabusediagnosisortreatmentrecommendedorrenderedtotheaboveidentifiedpatient.Iauthorizetheseagenciestoshareinformationbymail,phone,inperson,faxand/oremailcontact.IunderstandthattheserecordsareprotectedbyFederalandstatelawsgoverningtheconfidentialityofmentalhealthandsubstanceabuserecords,andcannotbedisclosedwithoutmyconsentunlessotherwiseprovidedintheregulations.IalsounderstandthatImayrevokethisconsentatanytimeandmustdosoinwriting.Arequesttorevokethisauthorizationwillnotaffectanyactionstakenbeforetheproviderreceivestherequest.

☐ IherebyauthorizeHealingMinds,LLCtoRELEASEmyprotectedhealthinformation(PHI)to:

☐ IherebyauthorizeHealingMinds,LLCtoOBTAINmyprotectedhealthinformation(PHI)from:

DISCLOSURESCOPEFORPHIRELEASE:Disclosuremayincludethefollowingverbalorwritteninformation:(checkallthatapply)

☐ Facesheet ☐ History&physical

☐ Laboratory/diagnostictestingresults ☐ Schoolinformation

☐ Dischargesummary ☐ Medicationrecords

☐ Behavioralhealth/psychologicalconsult ☐ Psychosocialassessment/Familyhistory

☐ ERrecordreport ☐ Psychiatricevaluation

☐ Substanceabusetreatmentrecords ☐ HIV/AIDSlabresults&treatmenthistory

☐ Progress&CaseNotes ☐ Summaryoftreatmentrecords&contactdated

☐ Psychologicalevaluation/testingresults ☐ Tense/unabletorelax

☐ Afraidtoleavehome ☐ Excessiveworry

☐ Inflatedselfesteem ☐ Panicattacks

☐ Feelguiltyorworthless ☐ Thoughtsofdeathorsuicide

☐ Other:

☐ Informationnecessarytoidentify,diagnose,prognosis,ortreatmentformentalhealth,substanceabuse(alcohol/druguse),andanyotherrelevantinformationforthepurposeoftreatment.

AllinformationIherebyauthorizetobeobtainedfromtheaboveidentifiedsourcewillbeheldstrictlyconfidentialandcannotbereleasedbyHealingMinds,LLCwithoutmywrittenconsent.Iunderstandthatthisauthorizationwillremainineffectfor:

☐Theperiodnecessarytocompletealltransactionsonaccountsrelatedtoservicesprovidedtome.

☐One(1)year

☐Other:

Iunderstandthatunlessotherwiselimitedbystateorfederalregulationandexcepttotheextentthatactionhasbeentakenwhichwasbasedonmyconsent,Imaywithdrawthisconsentatanytime.Ifclientisaminorchild,IverifythatIamthelegalguardian/custodianofthischild.SignatureofClient/LegalGuardianorLegallyAuthorizedRepresentative Date Witness Date

APPOINTMENTCANCELLATIONAGREEMENT

FirstName LastName

Eachmeetingisanotheropportunitytohelpyouconfidentlytakechargeandstartlivingthelifethat’simportanttoyou.Weunderstandthingscomeupandyoumayneedtomissyourappointment.Ifyouneedtorescheduleorcancelanyappointments,theofficeofHealingMindsrequires24businesshoursnotification(MondaythroughFriday8:00amto5:00pm).Pleaseunderstandthatwesetasidethistimeforyou,andifyouareunabletomakeit,wewillhavemissedanopportunitytomeetwithanothervaluableclient.Thispolicyisinplacetogivetheofficeenoughtimetoscheduleanotherclientinthattimeslot.Ifyoufailtocancelwithinthe48hourspriortoyourappointmenta$60feewillbechargedtothecardbeloworthecreditcardonfile.IfyouareaMedicaidorAmerigrouppatientyouarenotsubjecttothe$60fee,howeverafter1violationofthisagreement,servicesatthisofficewillbeterminated.

Whilewedocalltoremindyouofyourappointment,itisyourresponsibilitytocalltheofficeat775-448-9760,extension1,tocancel.

Iauthorizethefollowingcardtobeusedforco-paysandfee’sincurredduringthetimeIamapatientwithHealingMindsLLC.

CardNumber

Expires CVV

PrintedName

Signature Date

IunderstandthattheofficeofHealingMindsLLCwillattempttobillmyinsurance,howeverifmyinsurancedoesnotpay,forwhateverreason,Iamresponsibleforanyremainingbalance.Thismayincludedeductibles,copays,oroutofpocketexpenses.

Mysignatureacknowledges:

• InthecaseofaPsychiatricEmergencyIwillcall911orgotothenearesthospital• 7daysnotificationispreferredforanyprescriptionrenewals.• Iwilladheretotheguidelinesabovetothebestofmyability.

ClientName(pleaseprint)

Client/GuardianSignature Date