Child Intake Form This form is confidential Step 1 of 8 12% Today's Date* MM slash DD slash YYYY Your child's name* First Name Middle Name Last Name Parent or Legal Guardian's Name* First Name Middle Name Last Name Child's date of birth* MM slash DD slash YYYY Gender* Parent or Legal Guardian's Social Security #* Home Address* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent or Legal Guardian's Name of Employer* Employer Address* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Address NotesReferred byEmergency Contact PhoneWe will only contact this person if we believe it is a life or death emergency. Submission of this form represents an electronic signature indicating we may do so. Insurance Provider Group Number Subscriber ID EAP Authorization Number Co-pay Preferred Payment Method* Presenting ConcernTherapy GoalsExpectations Medical HistoryCurrent MedicationsMedical HospitalizationsPsychiatric HospitalizationsTherapeutic HistorySexual & Gender Identity Heterosexual Transgender Lesbian Asexual Gay In Question Bisexual Other Racial / Ethnic Identity African / African-American / Black American Indian / Alaska Native Asian / Asian-American / Asian Pacific Islander Bi-Racial / Multi-Racial Latino / Latino-American Middle Eastern / Middle Eastern-American White / European-American Not Listed / Decline to Answer Maternal RelationshipPaternal RelationshipAre the child's parents still married or did they divorce? Still married Divorced How old was the child when the parents separated or divorced and how do you think this impacted him or her?Grandparents RelationshipOther RelationshipsSisters Brothers Sibilng Relationships Rate your child's current level of satisfaction with friends and social support*ExcellentPoorPeer RelationsAbuse, Neglect, and / or TraumaSelf-care and Coping SkillsDiet, weight, and activitySchool PerformanceHobbies, Talents, and StrengthsAdditional Information Check all that apply to your child currentlyNowAnxietyDepressionMood ChangesAnger or TemperPanicFearsIrritabilityConcentrationHeadachesLoss of MemoryExcessive WorryWetting the BedTrusting OthersCommunicating with OthersSeparation AnxietyAlcohol / DrugsDrinks CaffeineFrequent VomitingEating ProblemsSevere Weight GainSevere Weight LossHead InjuryTantrumsParents DivorcedSeizuresCries EasilyProblems with Friend(s)Problems in SchoolFear of StrangersFighting with SibilngsIssues Re: DivorceSexually Acting OutHistory of Child AbuseHistory of Sexual AbuseDomestic ViolenceThoughts of Hurting Someone ElseHurting SelfThoughts of SuicideSleeping Too MuchSleeping Too LittleGetting to SleepWaking Too EarlyNightmaresSleeping AloneNauseaStomach AchesFaintingDizzinessDiarrheaShortness of BreathChest PainLump in the ThroatSweatingHeart ProblemsMuscle TensionBruises EasilyAllergiesOften Makes Careless MistakesFidgets FrequentlyImpulsiveWaiting His / Her TurnCompleting TasksPaying AttentionEasily Distracted by NoisesHyperactivityChills or Hot FlashesCheck all that apply to your child in the pastIn the PastAnxietyDepressionMood ChangesAnger or TemperPanicFearsIrritabilityConcentrationHeadachesLoss of MemoryExcessive WorryWetting the BedTrusting OthersCommunicating with OthersSeparation AnxietyAlcohol / DrugsDrinks CaffeineFrequent VomitingEating ProblemsSevere Weight GainSevere Weight LossHead InjuryTantrumsParents DivorcedSeizuresCries EasilyProblems with Friend(s)Problems in SchoolFear of StrangersFighting with SibilngsIssues Re: DivorceSexually Acting OutHistory of Child AbuseHistory of Sexual AbuseDomestic ViolenceThoughts of Hurting Someone ElseHurting SelfThoughts of SuicideSleeping Too MuchSleeping Too LittleGetting to SleepWaking Too EarlyNightmaresSleeping AloneNauseaStomach AchesFaintingDizzinessDiarrheaShortness of BreathChest PainLump in the ThroatSweatingHeart ProblemsMuscle TensionBruises EasilyAllergiesOften Makes Careless MistakesFidgets FrequentlyImpulsiveWaiting His / Her TurnCompleting TasksPaying AttentionEasily Distracted by NoisesHyperactivityChills or Hot FlashesMain Problem Family HistoryCheck all that apply Drug / Alcohol Problems Legal Trouble Domestic Violence Suicide Physical Abuse Sexual Abuse Hyperactivity Learning Disabilities Depression Anxiety Psychiatric Hospitalization "Nervous Breakdown" HIPPA Notification* The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surrounding the use of protected health information. Commonly referred to as the “medical records privacy law”, HIPAA provides patient protections related to the electronic transmission of data (“the transaction rules”), the keeping and use of patient records (“privacy rules”), and storage and access to health care records (“the security rules”). HIPAA applies to all health care providers, including mental health care, and providers and health care agencies throughout the country are now required to provide patients a notification of their privacy rights as it relates to their health care records. You may have already received similar notices such as this one from your other health care providers. As you might expect, the HIPAA law and regulations are extremely detailed and difficult to grasp if you don’t have formal legal training. My Patient Notification of Privacy Rights is my attempt to inform you of your rights in a simple yet comprehensive fashion. Please read this document as it is important you know what patient protections HIPAA affords all of us. In mental health care, confidentiality and privacy are central to the success of the therapeutic relationship and as such, you will find I will do all I can to protect the privacy of your mental health records. If you have any questions about any of the matters discussed in this document, please do not hesitate to ask me for further clarification. By law, I am required to secure your signature indicating you have received this Patient Notification of Privacy Rights Document. Thank you for your thoughtful consideration of these matters. I understand and have been provided a copy of Dr. Boyd’s Patient Notification of Privacy Rights Document which provides a detailed description of the potential uses and disclosures of my protected health information, as well as my rights on these matters. I understand I have the right to review this document before signing this acknowledgment form.Release of PHI I have read and fully understand the Notice of Privacy Practices for Protected Health Information (PHI) offered by Dr. William R. Boyd, Jr. and Stepping Stone Retreat for Enhanced Living, LLC. In general, HIPAA privacy rules give the right to request a restriction, or release of certain restrictions regarding the use and disclosures of protected health information (PHI). An individual may also request alternate means of correspondence for confidential and protected health information. Please check all that apply below. Home Phone May leave messages with detailed information Leave message with call back number only May leave message with family member, or other person (see below) Work Phone May leave message with detailed information Leave message with call back number only Written Communication May mail to home May mail to office May fax to number below May text to number below Preferred Appointment Day*Preferred Appointment DayMondayTuesdayWednesdayThursdayAny Day is FinePreferred Appointment TimePreferred Appointment TimeEarly Morning 8-10Mid Morning 10-12Early Afternoon 1-3Mid Afternoon 3-6Any Time is FinePreferred Appointment TimePreferred Appointment TimeEarly Afternoon 1-3Mid Afternoon 3-6Any Time is FineFax NumberText NumberI authorize the release of my PHI and medical information to the followingElectronic Submission* I understand that submission of this form constitutes an electronic signature authorizing the transmission of my information via email. Δ