Child/ Under 14 Registration – Affiliated Counseling Services

ALL SERVICES WILL BE VIRTUAL UNTIL FURTHER NOTICE.

Sessions will be done by video or phone until our return to the office. We do not anticipate returning to the office before 2021.

Child information

Please enter the following information about the child.

Name *

First

Middle

Last

Social Security Number

Date of Birth *//

Address

Address Line 1

Address Line 2

City

State

Zip Code

Sex

Male
Female
Other/Prefer not to say

Who can we thank for referring you to our practice?

Please tell us the name of the healthcare provider

Primary Insurance Company

Member ID

Group Number or Name

Whose insurance policy is this? (Name of Primary Subscriber)

Primary Insured's date of birth

Is the child covered by an additional Insurance company?

Yes
No
Not sure

Secondary Insurance Company

Member ID

Group number or name

Whose insurance policy is this?

Primary Insured's Date of birth (DD/MM/YYYY)

School

Grade

Name of Teacher or Guidance Counselor

Do we have permission to speak with your child's teacher or guidance counselor?

Do you and/or your child actively practice religion?

Yes
No
Somewhat
Prefer not to say

Has your child ever recieved psychiatric care before?

No
Yes
Unsure/other

If yes, briefly explain the reason for treatment

Parent and Family Information

Parent 1 *

First

Middle

Last

Date of Birth//

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent 2 *

First

Last

Date of Birth //

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are there established custody agreements for the child? *

Yes
No
Pending

Are the arrangements ordered or approved by the court?

Which parent has legal custody of the child? *

Parent 1 (above) has exclusive custody
Parent 2 (above) has exclusive custody
Parents 1 and 2 (above) equally share custody or are one household
Neither parent listed above has custody. Another party (named below) has custody

First

Middle

Last

Which parent has the legal right to make medical decsions on behalf of the child? *

Parent 1 (above) has exclusive rights to medical decisions
Parent 2 (above) has exclusive rights to medical decisions
Parents 1 and 2 (above) equally share rights to medical decisions
Neither parent listed above has this right. Another party (named below) has rights to medical decisions

(copy) *

First

Middle

Last

Please list family members and all others in child's primary home:

Please list any health conditions your child is currently recieving treatment for:

Please indicate the main reason you are seeking treatment

Early Childhood Development

Please answer each question as completely as possible and to the best of your knowledge about your child's life from birth to approximately age 5.

Describe prenatal care. Were there any illnesses?

Was he or she premature?

Yes
No
Not sure/Can't remember

Weight at birth (in pounds)

Height at birth (in inches)

Please describe any birth complications or problems

Was your child breast-fed ?

Yes
No
Not sure/Can't remember

If yes, how long was he or she breast fed?

Please list any allergies your child has or has outgrown

Please describe any sleep problems or patterns

What was their personality like?

At what age did your child do each of the following?

Sit without support?

Crawl?

Walk without holding on?

Help dress themselves?

Tie their own shoelaces?

Button buttons?

Ate with a fork?

Stayed dry all day?

Stayed dry all night?

Didn't soil his or her pants?

Said their first word understandable to a stranger?

Said their first sentence understandable to a stranger?

Section Divider

Please check all traits positive or negative that apply to your child

Affectionate
Argues, “talks back,” smart-alecky, defiant
Bullies/intimidates, teases, inflicts pain on others
Cheats
Cruel to animals
Concern for others
Conflicts with parents
Complains
Cries easily, feelings are easily hurt
Dawdles, procrastinates, wastes time
Difficulties with parent’s new partner
Dependent, immature
Developmental delays
Disrupts family activities
Disobedient, uncooperative, refuses, noncompliant, doesn’t follow rules
Distractible, inattentive, poor concentration, daydreams, slow to respond
Dropping out of school
Drug or alcohol use
Eating—poor manners, refuses, appetite increase or decrease, odd combinations, overeats
Exercise problems
Extracurricular activities interfere with academics
Failure in school
Fearful
Fighting, hitting, violent, aggressive, threatens, destructive
Fire setting
Lacks organization, unprepared
Lacks respect for authority, insults, dares, provokes, manipulates
Learning disability
Legal difficulties—truancy, loitering, panhandling, drinking, vandalism, stealing, fighting, drug sales
Likes to be alone, withdraws, isolates
Lying
Low frustration tolerance, irritability
Mental retardation
Moody
Mute, refuses to speak
Nail biting
Nervous
Nightmares
Need for high degree of supervision at home over play/chores/schedule
Obedient
Obesity
Overactive, restless, hyperactive, out-of-seat behaviors, restlessness, fidgety, noisiness
Oppositional, resists, refuses, does not comply, negativism
Prejudiced, bigoted, insulting, name calling, intolerant
Pouts
Recent move, new school, loss of friends
Relationships with siblings or friends/peers are poor—competition, fights, teasing/provoking, assaults
Responsible
Rocking or other repetitive movements
Runs away
Sad, unhappy
Self-harming behaviors—biting or hitting self, head banging, scratching self
Speech difficulties
Sexual—sexual preoccupation, public masturbation, inappropriate sexual behaviors
Shy, timid
Stubborn
Suicide talk or attempt
Swearing, foul language
Temper tantrums, rages
Thumb sucking, finger sucking, hair chewing
Tics—involuntary rapid movements, noises, or word productions
Teased, picked on, victimized, bullied
Truant, school avoiding
Underactive, slow-moving or slow-responding, lethargic
Uncoordinated, accident-prone
Wetting or soiling the bed or clothes

Consent for treatment

I certify that I, and/or my dependent(s), have insurance coverage and assign directly to Dr. Richard C. Blackford, PhD, PC DBA Affiliated Counseling Services all insurance benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid for by insurance or not. I authorize the use of my signature on all insurance submissions. The above-named entity may use my health care information and may disclose such information to the above-named Insurance Company or Companies and their agents for obtaining payment for services and determining insurance benefits or the benefits payable for related services. *

Your signature below indicates that you have the legal authority to consent for your child to be treated, you consent to have your child treated, you have read this agreement and agree to its terms, and also serves as an acknowledgment that you have read or received the HIPAA notice form described above. *

Phone