CAWM.NET, 4127 Embassy Drivegrandrapids, MI49456

CAWM.NET, 4127 Embassy DriveGrandRapids, MI49456

Ph616.264.3200Fax616.264.3201

Identification

Client(Child)InformationForm

Date:

Clientname:Dateof birth:Age: Nicknamesoraliases: SocialSecurity#: Homestreetaddress: Apt.: City: State: Zip: Primary phone: Other phone: Secondary phone:

e-mail: Callsore-mailwillbediscreet, butpleaseindicate any restrictions: Parentorlegalguardianname(s): Areyouthelegalguardianofthischild?❑Yes ❑No

Referral:

Who referredyoutous? Name:Phone:

Maywehaveyour permission tothankthispersonforthe referral?❑Yes❑No

Howdidthispersonexplain howImightbeof help to you?

Your medical care: Fromwhomorwheredoyougetyourmedicalcare?

Clinic/doctor’sname:Phone: Address: IfyouentercounselingwithCAWM,maywetellyourmedicaldoctorsothatheorshecanbefully informedand wecancoordinate your treatment?❑Yes ❑No

Religious and racial/ethnic identification: Currentreligiousdenomination/affiliation

❑Protestant❑Catholic❑Jewish❑Buddhist❑Hindu

Other(specify): Involvement:❑None❑Some/irregular❑Active

Howimportantarespiritualconcernsinyourlife?

School

SchoolName:Phone: Address: Grade/year in college: Teacher’sname______

Callswillbediscreet,butpleaseindicateany restrictions:

Emergency information

If somekindof emergency ariseswhomshould wecall?

Name:Phone: _Relationship: Address:

Appointment, Fee & Consent for Treatment Information

TherapyAppointments:Weoftenscheduleseveralappointments inadvanceso thatyoucanplantomake therapysessionsa priorityinyour busyschedule.

Fees:Cancelledappointmentsdelaytherapywork.Thetimewehavereservedforyouisveryimportantforyourcare.Pleasetrynottomisssessionsifyoucanpossiblyhelpit.Whenyoumustcancel,please give atleast48hours notice.

LateFee:Cancellationsmadelessthan24hoursofabusinessdayinadvanceofyourappointmentwillbebilledasfollows:½sessionchargeforthefirstlatecancelandafullsessionchargeforthesecondandthereafter.Your insurance willnot cover this charge.

Paymentis expectedattime of service.We acceptcash,checks,creditand debit.

Masters-LevelLicensed Certified SocialWorkers,Therapists

CPTCode

Schoolmeetings $130/hour including transportationtime

***Insurancerarelycoversprofessionalservicefees,telephoneconsultsorschoolmeetings;theseservicesarebilledatthehourlyrate,proratedovertime.Thereisnochargeforcallsaboutappointmentsorsimilarbusiness.Psychologicaltesting:Testingfeesincludetimespentwithyou,timeforscoringandstudyingresults,andtimetowriteareportonthefindings,ifareportisdesired.Theamount oftimedependsontestsused and questionstesting isintended toanswer.

Weassumeyouareapatientuntilyoutellusinperson,byphone,ormailthatyouwishtoendtreatment.You mustpayfor anyservices you receive before endingthe relationship.

Please balance your accountbythe endof eachmonth.

Ifyouthinkyoumayhavetroublepayingyourbillsontime,pleasediscussthiswithyourtherapist.Shewillalsoraise the matter withyou soyou canarrive ata solution.Ifyour unpaid balance reaches

$200,you willbe notified bymail.Ifitthenremains unpaid,we muststop therapywithyou.Patients whoowe andfailtomake arrangements topaywillbe referred for collections.

A latefeeof1%oftheunpaidbalancewillbechargedeachmonththatabalanceremainsunpaid.Ifthereisaproblemwithourcharges,billing,yourinsurance,oranyothermoney-relatedpoint,pleasebring ittoour attentionimmediately.Suchproblems interfere greatlywithyour therapy work.

PleaseInitialherewhenyouhaveread thispage

HealthInsuranceCoverage:Becausewearelicensedmentalhealthproviders,manyinsuranceplanswillhelppayforourservices.Everyinsuranceplanisdifferent.Youareresponsibleforcheckingyourinsurancecoverage,deductibles,paymentrates,copayments,andsoforth.Wewilltryourbesttomaintaintheprivacyaswebillyourinsurance,butpleasedonottohold CAWMresponsiblefor accidentsthat may happenas a result.***Therearecertaininsurancecompanieswithwhomwedonotparticipate.Inthesecases,youmayhavecoverageforourservices,butweaskthatyoupayforyourservicesinfullupfrontandwewillgiveyouaninvoicefortheservicesyoureceivewiththestandarddiagnosticandprocedurecodes,timesmet,charges,andpayments.Youcanusethistoapplyforreimbursement.Pleaseaskyourcounseloriftheyparticipatewithyour insurancecarrier.

If youhavenohealthinsurancecoverage,ordonot intend touseit,pleasecheckhere❑,Skip thissection.If youwillbeusing insurance,pleasecompletethefollowing:

PrimaryInsurance Company:_ Nameofsubscriber(ifnot thepatient): Subscriber'sDateofBirth ID/policy #: Grouporenrollment #: Plan#/codeorBS #: _ Effectivedate: Addresstosend claims: Phone: Doesyour insurancerequireauthorizationforourservices?❑Yes ❑No

Isthe CAWMprovideryou wishtoseecovered underthisinsuranceplan?❑Yes ❑No

Did you calltoget authorization?Authorization#?What isyourdeductible:$❑perpersonor❑per family? or❑perdiagnosis?

❑per fiscalyear or❑per calendaryearor❑perpolicyyear?Howmuchofthisdeductiblehasbeenused sofar? $

Benefit:%of❑charges❑Usual,customary,and reasonable(UCR)❑Max.chargeof$

Limitations: Numberofvisits:Monetarylimits:$_per_Lifetimelimits:$ Isoutpatient grouppsychotherapycovered? ❑Yes ❑No

Must a physicianrefer theclient? ❑Yes❑No

Ispsychologicaltesting covered?❑Yes❑No

Doesanyruleabout preexisting conditionsapply here? ❑No❑Yes, and theruleis:

Arethereanyotherlimitations(such asconditionsnotcovered,servicesettings,maximumper-sessioncharges,needforDSMor ICDdiagnostic codesor CPTservicecodes)?

Insurance release:IgiveCAWMpermissiontoreleaseanyinformationobtained during treatment ofthis patient that isnecessary tosupport anyinsuranceclaimsonthis account and securetimelypaymentsduetotheassigneeormyself. FinancialResponsibility:Iunderstand thatIam responsibleforallcharges,regardlessof insurancecoverage. Ialsounderstand that ifIdonot giveat least 24hours ofa businessdaynoticethatIwillmiss a scheduled appointment,mytherapist reservestheright tochargeme50% ofherhourlyrateforthefirst missed appointment and 100% ofherhourlyratethereafter. Iamawarethatmy insurancecompany will not coverthesecharges.

Assignmentof benefits:I herebyassignmedicalbenefits,including thosefromgovernment-sponsored programsand otherhealthplans,tobepaid toCounselingAssociatesofWest Michigan.Medicareregulationsmayapply.Aphotocopy ofthisassignment istobeconsidered asgood astheoriginal.

Signatureof Client (or parent/guardian’s)Printed NameDateindicating agreement toallofthestatementsabove

TherapyAgreement/ConsentforTreatment: I,(orhis/herguardian),understandIhavetherightnot tosignthisform.My signaturebelowindicatesI have read thisagreementand had anyquestionsanswered;it doesnotindicatethatIamwaivinganyofmyrights.Iunderstandthatanyofthepointsmentionedinthisdocumentcanbediscussedandmaybeopentochange.IfatanytimeduringthetreatmentIhavequestionsaboutanyofthesubjectsdiscussedinthisbrochure,Icantalkwithmytherapistaboutthem,ands/hewilldoherbesttoanswerthem.IunderstandthataftertherapybeginsIhavetherighttowithdrawmyconsenttotherapyatanytime,for anyreason.However,Iwillmakeeveryeffort todiscussmyconcernsabout myprogresswithmycounselorbeforeending therapy.

Iunderstandthatnospecificpromiseshavebeenmadetomebythistherapistabouttheresultsoftreatment,theeffectivenessoftheproceduresusedbythistherapist,orthenumberofsessionsnecessaryfortherapytobeeffective.
Ihaveread,orhavehadreadtome,theissuesandpointsinthisbrochure.IhavediscussedthosepointsIdidnotunderstand,andhavehadmyquestions,ifany,fullyanswered.I agreetoactaccordingtothepointscoveredinthisbrochure.Iherebyagreetoenterintotherapywiththistherapist(ortohavethecliententertherapy),andtocooperatefully and tothebest ofmyability,asshownbymysignaturehere.

Signatureof client(orpersonactingforclient)Printed NameDateRelationshiptoclient: ❑Self❑Legalguardian❑Custodial parent of minor (less than 14 years of age)

CAWM.NET, 4127 Embassy DriveGrandRapids,MI49456

Ph. 616.264.3200 Fax. 616.264.3201

Checklist and DevelopmentalHistory

Date: ______

Child name: ______DOB______

Person Completing Form ______

Relationship to child ______

Parents arecurrently❑Married❑Divorced❑Remarried❑Never married❑Other:

Mother’s (and father’s or step-father’s)name: Father’s (and step-mother’s name:

Please check concerns:

❑Affectionate

❑Argues,“talksback,”smart-alecky,defiant

❑Anxiety

❑Bullying issues

❑Cheats

❑Crueltoanimals

❑Conflictswithparentsover(list):

❑Complains

❑Crieseasily,feelingsareeasilyhurt

❑Dawdles,procrastinates,wastestime

❑Difficultieswithparentdating/newmarriage/newfamily

❑Dependent,immature

❑Depressed

❑Developmentaldelays

❑Disruptsfamilyactivities

❑Disobedient,noncompliant

❑Distractible,inattentive,poorconcentration

❑Droppingoutofschool

❑Drugoralcoholuse

❑Eating—appetiteincrease/decrease,overeats

❑Exerciseproblems

❑Extracurricularactivitiesinterferewithacademics

❑Failureinschool

❑Family changes, parental divorce or separation

❑Fearful

❑Aggressive,hostile,threatens,destructive

❑Firesetting

❑Friendly,outgoing,social

❑Complainsof“sickness” frequently

❑Immature

❑Imaginaryplaymates,fantasy

❑Independent

❑Interrupts,talksout,yells

❑Lacksorganization,unprepared

❑Learningdisability

❑Legalproblems:

❑Likestobealone,withdraws,isolates

❑Lying

❑Lowfrustrationtolerance,irritability

❑Mentalretardation

❑Moody

❑Mute,refusestospeak

❑Nailbiting

❑Nervous

❑Nightmares

❑Needforhighdegreeofsupervision

❑Obedient

❑Obesity

❑Obsessive/Repeats words or behaviors

❑Overactive,restless,hyperactive

❑Oppositional,resists,negative

❑Perfectionistic

❑Prejudiced,insulting,namecalling,intolerant

❑Pouts

❑Recentmove,newschool,lossoffriends

❑Relationshipsarepoor/Friendship issues

❑Responsible

❑Rockingorotherrepetitivemovements

❑Runsaway

❑Sad,unhappy

❑Self-harmingbehaviors

❑Speechdifficulties

❑Sexualproblems:

❑Sleep issues/falling asleep or staying asleep

❑Shy,timid

❑Stubborn

❑Suicidetalkorattempt

❑Swearing,foullanguage

❑Tempertantrums,rages

❑Thumbsucking,fingersucking,hairchewing

❑Tics—involuntaryrapidmovements,noises,orwords

❑Teased,pickedon,victimized,bullied

❑Trauma history or trauma event

❑Truant,schoolavoiding

❑Underactive,slow-movingorslow-responding,lethargic

❑Uncoordinated,accident-prone

❑Wettingorsoilingthebedorclothes

❑Workproblems

❑Anyothercharacteristic

PresentingIssues:Whatarethemainreasonsyoubroughtthischildinfortreatment?

Pleasegiveabriefhistoryoftheseproblems(whentheybegan,attemptedsolutions,etcetera).

Medical:Doesthischildhaveanycurrentmedicalproblems?❑No❑Yes Pleasedescribe.

Doesthischildhaveahistoryofmedicalproblems(startingwithpregnancy)?❑No❑YesPleasedescribeindetail.

Hasthechildeverreceivedpsychological,psychiatric,substancetreatmentbefore?❑No ❑YesPleasedescribe.

Hasthechildevertakenmedicationsforpsychiatricoremotionalproblems? ❑No❑YesPleasedescribe.

Family:Pleasedescribethefollowing:

Thechild’sparents’relationshipwitheachother:

Thechild’srelationshipwitheachparentandwithanyotheradults(stepparents,teachers,etc.):Thechild’srelationshipwithbrothersandsisters:

FamilyPsychiatricHistory:

Familyoforigin:hasthischild’smother,father,brothersorsisterseverexperiencedemotionalproblems?

❑No❑Yes Pleasedescribeindetail.

Extendedfamily:hasthischild’sgrandparents,aunts,unclesorcousinseverexperiencedemotionalproblems?

❑No❑Yes Pleasedescribeindetail.

Child’seducation:

Doesthischildhaveanyeducationalinterventionsatschool(speech,504plan,IEP)?❑No❑YesPleasedescribe:

Isthischildhavingacademicproblems?❑No❑YesPleasedescribe.

Describethischild’srelationshipswithpeers(friends,socialdifficulties,etc.):

Pleaselistextracurricularactivities/specialtalents/skillsthischildhasbeen/isinvolvedin:

Abusehistory:❑Thischildwasnotabusedinanyway.❑Thischildwasabused.Ifabused,pleasedescribe.

Chemicaluse:Howmanysodas/popwithcaffeinedoesthischildconsumeperday? Hasthischildeversmokedordrankalcohol? ❑No ❑Yes

Pleasedescribe:

Isthischildlegallyrequiredtohavethisappointment?❑No❑Yes PleaseDescribe.

CAWM.NET, 4127 EmbassyDriveGrand Rapids, MI49456

Ph.616.264.3200 Fax.616.264.3201

Noticeof Privacy Practices (BriefVersion)

THISNOTICEDESCRIBESHOWMEDICALINFORMATIONABOUTYOUMAYBEUSED ANDDISCLOSEDANDHOWYOUCANGETACCESSTOTHISINFORMATION.PLEASEREVIEWITCAREFULLY.

Ourcommitmenttoyourprivacy.CounselingAssociatesofWestMichigan,LLC,isdedicatedtomaintainingtheprivacyofyour personalhealthinformationaspartof providingprofessionalcare.Wearealsorequiredbylawtokeepyourinformationprivate.Theselawsarecomplicated,butwemustgiveyouthisimportantinformation.Thisisashorterversionofthefull,legallyrequired noticeof privacypractices.Pleasetalktoourprivacyofficer(seeend of form)about anyquestionsorproblems.

Howweuseanddiscloseyourprotectedhealthinformationwithyourconsent.Wewillusetheinformationwecollectaboutyou mainlytoprovideyou withtreatment,toarrangepaymentfor our services,andfor some other businessactivitiesthatarecalled, inthelaw,healthcareoperations.Afteryouhavereadthisnoticewewill askyoutosignaconsentformtoletususeand shareyourinformationintheseways.If youdonotconsent and signthis form,wecannot treat you.If wewant to useorsend,share,orreleaseyourinformationforotherpurposes,wewilldiscussthiswithyouandaskyoutosignanauthorizationform.

Disclosingyourhealthinformationwithoutyourconsent.Therearesometimeswhenthelawsrequireustouseorshareyourinformation.Forexample:

1.Whenthereisaseriousthreattoyouroranother’shealthandsafetyortothepublic.Wewillonlyshareinformationwithpersonswho areabletohelpprevent orreducethethreat.

2.Whenwearerequired todosobylawsuitsand otherlegalorcourt proceedings.

3.Ifa law enforcement officialrequires us todoso.

4.Forworkers’ compensationand similarbenefit programs.

Therearesomeotherraresituations.They aredescribed in thelongerversionofournoticeofprivacypractices.

Your rights regardingyour health information

1.Youcanaskustocommunicatewithyouinaparticularwayoratacertainplacethatismoreprivateforyou.Forexample,youcanaskustocallyouathome,andnotatwork,toscheduleorcancelanappointment.We tryourbesttodoasyouask.

2.Youcanaskusto limit what wetellpeopleinvolved inyour careorpayment foryourcare,suchasfamilyand friends.

3.You havetherighttolookatthehealthinformation we haveaboutyou,suchasyour medicalandbillingrecords. Youcanget a copyoftheserecords,but wemay chargeyoufor it.Contact ourprivacyofficertoarrangehowtoseeyourrecords.

4.Ifyoubelievethattheinformationinyourrecordsisincorrectormissingsomethingimportant,youcanaskustomakeadditionstoyourrecordstocorrectthesituation.Youhavetomakethisrequestinwritingandsendittoourprivacyofficer.Youmustalso tell us thereasonsyouwant tomakethechanges.

5.Youhavetherighttoacopyofthisnotice.Ifwechangethisnotice,wewillpostthenewversion inourwaitingarea,andyoucanalwaysget a copyof itfromtheprivacyofficer.

6.Youhavetherighttofileacomplaintifyoubelieveyourprivacyrightshavebeenviolated.YoucanfileacomplaintwithourprivacyofficerandwiththeSecretaryoftheU.S.DepartmentofHealthandHumanServices.Allcomplaintsmustbeinwriting.Filingacomplaintwillnotchangethehealthcareweprovidetoyouinanyway.Also,you mayhaveotherrightsthataregranted toyoubythelawsofourstate,and thesemaybethesameasordifferentfromtherightsdescribed above.Wewillbehappytodiscussthesesituationswithyounoworastheyarise. Ifyouhaveanyquestionsregardingthisnoticeorourhealthinformationprivacypolicies,pleasecontactourprivacyofficer,Who is Mary Lier, LMSW ACSW who can be reached at rbycalling 616.264.3200.

Theeffectivedateofthisnoticeis3/01/2014

ConsenttoUseandDiscloseYourHealthInformation

Thisformisanagreementbetweenyou,andus.Whenweusethewords“you”and“your”below,thiscanmeanyou,yourchild,arelative, orotherpersonasfollows: .

Whenweexamine,test,diagnose,treat,orreferyou,wewillbecollectingwhatthelawcalls“protectedhealthinformation”(PHI)aboutyou.Weneedtousethisinformationinourofficetodecideonwhattreatmentisbestforyouandtoprovidetreatmenttoyou.Wemayalsosharethisinformationwithotherstoarrangepaymentforyourtreatment,tohelpcarryoutcertainbusinessorgovernmentfunctions,ortohelpprovideothertreatmenttoyou.Bysigningthisform,youarealsoagreeingtoletususeyourPHIandtosendittoothersforthepurposesdescribedabove.Yoursignaturebelowacknowledgesthatyouhavereadorheardournoticeofprivacypractices,whichexplainsinmoredetailwhatyourrightsareandhowwecanuseandshareyourinformation.

Ifyoudonotsignthisformagreeingtoourprivacypractices,wecannottreatyou.Inthefuture,wemaychangehowweuseandshareyourinformation,andsowemaychangeournoticeofprivacypractices.Ifwedochangeit,youcangetacopyfromourwebsite,

IfyouareconcernedaboutyourPHI,youhavetherighttoaskusnottouseorsharesomeofitfortreatment,payment,oradministrativepurposes.Youwillhavetotelluswhatyouwantinwriting.Althoughwewilltrytorespectyourwishes,wearenotrequiredtoaccepttheselimitations.However,ifwedoagree,wepromisetodoasyouasked.Afteryouhavesignedthisconsent,youhavetherighttorevokeitbywritingtoourprivacyofficer.WewillthenstopusingorsharingyourPHI,butwemayalreadyhaveusedorsharedsomeofit,andwecannotchangethat.

Signatureofclient orhisorherpersonalrepresentativeDate

Printednameofclient orpersonal representativeRelationshiptotheclient

Descriptionofpersonalrepresentative’sauthority

Signatureofauthorizedrepresentativeofthisofficeorpractice

DateofNPP:

❑Copygiventotheclient/parent/personalrepresentative