Bismarck LocationMinot Location
2625 N 19th Street2080 36th Ave SW Suite 110
Bismarck, North Dakota 58503Minot, ND 58701
Phone: 701-222-3175
Fax: 701-222-3186
Red Door General Intake
Our evaluation of your child will depend on information about his/her past history. Fill out this form as completely as possible and bring with you the day of the evaluation. If you have questions regarding any items, put a checkmark in the left margin and we can discuss them when you come for your appointment.
Today’s date:______
Person completing form (first/last name):______Relationship to child:______
If you are not the child’s current legal guardian, please list the legal guardian:______
IDENTIFICATION:
Child’s full name: ______Birthdate:______Sex: _____ Age: ______
Who does the child live with? ______
Address of child’s primary residence: ______
City: ______State: ______Zip: ______
Mother / FatherName: / Name:
Age: DOB: / Age: DOB:
Cell phone #: / Cell phone #
Home phone # (if different than cell phone #s):
Place of Employment: / Place of Employment:
Occupation: / Occupation:
Work phone #: / Work phone #:
Email: / Email:
Preferred method of contact (phone call or email):
Emergency contact (name and phone number):
Relationship to child:
Siblings:
Name / Age / Sex / Grade / Speech/language, OT, medical conditions:PHYSICIAN INFORMATION:
Child’s Primary Doctor:______
PREGNANCY/BIRTH HISTORY:
Which pregnancy was this child?______Were there any illness, diseases, or accidents that occurred during pregnancy?______
______
Was there in utero exposure to drugs or alcohol? ______
Age of mother at child’s birth:______Age of father at child’s birth:______
Length of pregnancy: / Type of delivery:Birth weight: / Apgar scores:
Length of labor: / Was labor difficult?
Was medical intervention needed during labor/delivery (if yes, please explain (ex. induction, forceps, epidural, blood transfusion, etc.)? ______
Were there any bruises, scars, or abnormalities to the child’s head? ______
Did the child require oxygen? yes / no Was child “blue”? yes / no Was the child jaundice? yes / no
Were there any problems immediately following birth or during the first two weeks of the child’s life (ex. NICU, nursing, swallowing, sucking, feeding, sleeping, etc.)? If so, describe: ______
______
DEVELOPMENTAL HISTORY:
At what age did the child develop the following skills:
Rolled over alone: / Sat alone: / Crawled:Stood alone: / Walked unaided: / Fed self with spoon:
Bladder trained: / Bowel trained: / Consumed solid foods:
First word: / First phrase: / Conversation:
Do you have: / YES / NO
Communication concerns
Fine motor concerns
Gross motor concerns
Sensory concerns
Please describe the child’s overall social behavior? ______
The child prefers to: Play alone______Parallel play______Play with others______
(*parallel play is to play alongside other children, but not with other children)
MEDICAL HISTORY:
Is the child now under the care of a doctor?______Why?______
Does the child currently carry any medical diagnoses?______If yes, please indicate diagnoses, medical professional who made the diagnoses, and date of diagnoses: ______
______
Is he/she taking medication?______Type?______
Is he/she taking supplements?______Type? ______
At what age did any of the following occur? Indicate severity.
Age / Mild / Mod / Severe / Age / Mild / Mod / SevereAdenoidectomy / Influenza
Chronic colds / PE tubes
Cross-eyed / Pneumonia
Croup / Strep throat
Earaches/ear infections / Seizures
Headaches / Tonsillectomy
Heart murmur / Whooping cough
Other:
Known allergies:______
Has the child ever had an extremely long, high fever?______If yes, please explain: ______
______
Has the child ever fallen or had a blow to the head?______If so, did he/she lose consciousness?______
Did it cause a concussion?____ Did it cause nausea?_____ Vomiting?_____ Did any of the above require hospitalization?______
Surgical history:______
______
Is the child currently seen by a Chiropractor? ______
When was the last time the child has been to the dentist?______Any concerns reported?______
If yes, explain:______
When was the last time the child has been to the eye doctor?______Any concerns reported?______
If yes, explain:______Does your child currently wear glasses?______
When was the last time the child has had his/her hearing checked?______Any concerns reported?___
If yes, explain:______
Check these as they apply to your child.
Yes / No / Explain:Eating problems
Sleeping problems
Toilet training problems
Difficulty concentrating
Difficulty staying with an activity
Requires a lot of discipline
Underactive
Overactive
Cries a lot
Sensitive/Emotional
Likes rough play
Irritable
Difficulty getting along with children
Difficulty getting along with adults
Difficulty making friends
Has frequent tantrums
Frequently fearful
Gets stuck on topics
Obsessions/compulsions
Avoids eye contact
Has limited interests
Confused by gestures
Misinterprets social situations
Falls, trips often, or is overall “clumsy”
Walks on tiptoes often or feet turn inward with walking
Difficulty with coordination, running, or jumping tasks compared to peers
Does the child separate from his/her caregivers without crying or fussing?______
Are you concerned with your child’s behavior?______If so, what is most concerning to you? ______
How do you deal with negative behaviors or what discipline method works best? ______
Favorite play or motivating activities for your child?______
______
EDUCATIONAL HISTORY:
Does the child attend daycare?______Where?______
How many hours per week?______Does the child attend school?______
Where?______Is your child on an IFSP or IEP?______
Grade?______What are his/her average grades:______Best subjects:______
Challenging subjects:______Is the child frequently absent from school?______
If so, why?______
How does the child feel about school or his/her teacher?______
Has anyone ever thought he/she has learning difficulties (ex., dyslexia)? ______
______
Describe any speech, language, hearing, occupational/physical therapy, psychological, or special education services that your child is currently enrolled in. How often does your child attend this service? ______
______
ADDITIONAL INFORMATION:
What are your primary concerns and reasons for seeking an evaluation:______
______
______
______
Please add any additional information you want us to know :______
______
______
How did you hear about Red Door? ______
DIAPER AND TOILETING PROCEDURES:
When necessary, Red Door Pediatric Therapy staff may change a child’s diaper and/or provide toileting assistance under the following conditions:
-consent has been signed (see below)
-it is understood that no application of creams, powders, or ointments will be administered
-it is understood that parents/caregivers are responsible for providing diapers, wipes, and a change of clothes in the event of an accident
Consent for Diaper Changing:
I, ______, give permission for Red Door Pediatric Therapy staff to change
(print parent/guardian name)
______’s diaper and/or assist with toileting as necessary. I understand and agree
(print child’s name)
to the terms listed above. I also understand that I may revoke this permission at any time.
Parent/guardian’s signature:______
Date: ______
CONFIDENTIALITY
As mandated by law, we are required to report any suspected child molestation, neglect and emotional or physical abuse to protect the children involved.
______Initials ______Date
Signature of person filling out form:______Date:______
Insurance Information
Primary coverage:
Child name:Policyholder:
Policy ID number:
Group number:
Insurance provider number:
Insurance Company Name:
Address:
Phone Number:
Secondary coverage if applicable:
Child name:Policyholder:
Policy ID number:
Group number:
Insurance provider number:
Insurance Company Name:
Address:
Phone Number:
I hereby acknowledge that the information provided above is accurate and current:
Signature______Date:______
Notice of Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Introduction: This notice describes how Red Door Pediatric Therapy handles information about you—how information is used in the office, how information might be shared with other professionals and organizations, and how that information can be accessed. It is important to understand these policies so that the best decisions for you and your family can be made about personal and medical health information. It is a requirement to provide this information to you as a result of privacy regulations of a federal law and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Each time there is a visit by any healthcare provider, information is collected about your physical and mental health. The information is called, according to HIPAA, Protected Health Information (PHI). This information goes into a healthcare record within our office. This information is likely to include the following:
●Past history: childhood, school, work and marital history
●Reason for seeking treatment
●Diagnosis/diagnoses
●Progress notes
●Records from other practitioners treating your child
●Legal matters
●Insurance and billing information
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
●“PHI” refers to information in your health record that could identify you.
●“Treatment, Payment and Health Care Operations” (TPO)
○Treatment is when we provide, coordinate or manage health care and other services related to your health care. An example of treatment would be consulting with another health care provider, such as family physician or another therapist.
○Payment is obtained reimbursement for your health care. We may disclose PHI to the health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
○Health Care Operations are activities that relate to the performance and operation of this practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
●“Use” applies only to activities within the office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
●“Disclosure” applies to activities outside of this office such as releasing, transferring, or providing access to information about you to others.
●“Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form
II. Other Uses and Disclosures Requiring Authorization
We may use or disclose PHI for other purposes than treatment, payment, or health care operations(TPO) when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. You can revoke all such authorizations (of PHI) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures Not Requiring Consent or Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
●Child Abuse – If I have reasonable cause to suspect or believe that any child under the age of eighteen years (1) has been abused or neglected, (2) has had non-accidental physical injury, or injury which isn’t consistent with the history given of the injury, or (3) is placed at imminent risk of serious harm, then we are required by law to report this suspicion or belief to the appropriate authority.
●Adult and Domestic Abuse – If we know or in good faith suspect that an elderly individual or an individual, who is disabled or incompetent, has been abused, we may disclose the appropriate information as permitted by law.
●Health Oversight Activities – If a professional oversight organization is investigating this practice, they may subpoena records relevant to such investigation.
●Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records, this information is privileged under state law, and we will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
●Serious Threat to Health or Safety – If we believe in good faith that there is risk of imminent personal injury to you or to other individuals or risk of imminent injury to the property of other individuals, we may disclose the appropriate information as permitted by law.
●Worker’s Compensation – We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s 4 of 5 compensation or other similar programs, established by law, that provide benefits for work related injuries or illness without regard to fault.
IV. Client’s Rights and Therapist’s Duties:
Patient Rights
●Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.
●Right to Receive Confidential Communications by Alternative Means and at Alternative Location – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are attending this clinic. On your request, we will send your bills to another address.)
●Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in our health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.
●Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
●Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, we will discuss with you the details of the accounting process.
●Right to a Paper Copy – You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.
●Therapist’s Duties: We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI 5 of 5.
●We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
●If we revise our policies and procedures, we will notify you by U.S. mail or in person during our session. When information is disclosed, we will disclose the minimum amount of information necessary to address the reason the information was requested.
V. Complaints
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Heather Arnt or Kelli Ellenbaum. They can be reached at 701-222-3175. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The Privacy Officer can provide you with the appropriate address upon request.
VI. Effective Date
This notice will go into effect on September 15, 2009.
Summary Notice of HIPPA Privacy Practices
We may share your health information to: treat you, get paid, run the clinic, tell you about other health benefits/services, raise funds, tell family and friends about you, do research, health and safety reasons, military purposes, workman’s comp requests, lawsuits, law enforcement, national security reasons, coroner, medical examiner or funeral director use.
YOU HAVE THE RIGHT TO: get a copy of your medical record, change your medical record if you think it is wrong, get a list of whom we share your health information with, ask us to limit the information we share, ask for a copy of our privacy notice, and complain in writing to the clinic if you believe your privacy rights have been violated.
INDIVIDUAL AUTHORIZATION FOR USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your written authorization before we may use or disclose your protected health information for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information may be used or disclosed. Please read the information above carefully before signing this form.
Patient Name: ______
Parent/Guardian/Legal representative of Patient:
______Date:______
Bismarck LocationMinot Location
2625 N 19th Street2080 36th Ave SW Ste 110
Bismarck, ND 58503Minot, ND 58701
Phone: 701-222-3175
Fax: 701-222-3186
Attendance Policy
Welcome to Red Door Pediatric Therapy!
Several factors go in to scheduling your child’s evaluations and subsequent appointments including therapy recommendations, insurance approval/parameters, and convenience/availability of preferred times for your family.
Maintaining a consistent therapy schedule is critical to achieve progress toward short and long-term objectives. Because of the demand for therapy services and to ensure positive outcomes on your child’s plan of care, we would like to highlight the following attendance policy: