Child Intake Form

Child Intake Form 2019-01-02T00:20:36+00:00
Child Intake Form
0% Complete
1 of 12

INFORMATION AND CONSENT FOR CHILD/FAMILY PSYCHOTHERAPY

For the best results and for your child’s welfare, it is very important that you take a few minutes to read and understand what it means for your young one to be in psychotherapy.  This form provides a brief description of what you might expect if you haven’t had them in therapy before.  If you understand the information on this form and choose to begin treatment sign and date this form and return it to your child’s therapist upon intake. If you have any questions or concerns about the information on this form, you are urged to discuss them with your child’s therapist.

Psychotherapy is a special kind of health care service.  The goals of psychotherapy are to help children and parents find solutions to problems that may be limiting their lifestyle satisfaction, and to help them cope better with the feelings and challenges that your child may be encountering in their daily life.

The most common method of psychotherapy involves the child talking about their thoughts and feelings, problems or concerns, and their experiences.  Other common methods involve the use of their imagination, active play and role-playing, keeping personal journals of their experiences, and trying new and/or different ways of thinking, acting, or feeling.  These methods may be used within treatment sessions or you may be asked to do them together at home.

To better understand your child’s, thoughts and feelings, many psychologists use a variety of tests or measures to estimate their current abilities and ways of experiencing things.  These measures are important in choosing the treatment method that is best suited for your child, and they are also helpful in estimating their progress.

The length of treatment often depends on your individual goals as a parent and the rate of their progress toward the agreed upon goals.  Many psychologists use periodic reviews as a means of evaluating your needs, progress, and satisfaction.

Most children benefit from psychotherapy.  The most common benefits include improvements in self-awareness, self-esteem, self-confidence, organization, hope, feeling understood, relationships with other people, emotional expressiveness, and taking an active and responsible role in life.  There are also some risks to being in psychotherapy.  The most common risks are temporary periods of emotional distress related to changes in their life situation and their changing relationship with yourself and others (including your therapist).  This is typically viewed as therapeutic growth and can be met with resistance.  Psychological harm caused by psychotherapy is rare, but you should be aware that it could happen.  The most common causes of such harm are poor communication or unethical conduct.  If you feel that your child is not making reasonable progress or that they are being harmed by their involvement in psychotherapy, you should discuss this with your therapist immediately.  If you feel that your therapist has attempted to violate you or your child in any way – financially, physically, sexually, or otherwise – you should inform the state licensing board.

You always have the right to choose whether or not to continue in psychotherapy.  If you feel that you and your child might work better with a different therapist, your current therapist should be able to offer information on alternative referrals.  Local mental health agencies are listed in the telephone book and may also offer helpful information.  The more common alternatives to psychotherapy are:  self-help or support groups, therapeutic reading, and different forms of religious counseling.

Communication is essential to successful psychotherapy.  You are urged to ask questions, express concerns, and share information about your personal and family life with your child’s therapist.  This information will be kept confidential (private) by your therapist unless you grant permission to release it to a third party.  The ONLY EXCEPTIONS to this protection of your privacy are dictated by state laws.  For example, your therapist is legally obligated to report incidents of child abuse or threats of violence that may place you or another identified person in danger of personal harm.  You are urged to discuss this issue and the limits of confidentiality with your child’s therapist.

Your signature below indicates that you have read and understood the above description of psychotherapy and consent to have your child in psychotherapy with the understanding that you retain the right to review and revise the decision at a later time.

Please note that all name fields will also be treated as this form being digitally signed. Dr. Malcolm Anderson Ph.D. may also require this form be physically signed at the practice.

Booking Fee Notice

Please note that at the end of this form you will be required to make a payment with your credit card and secure your first session with Dr. Malcolm Anderson. Without this payment, the form will not be submitted and the booking will not be made. If you are unable to make payment at this stage, please do not continue with the intake form and contact our office at (770) 582-0532 or therapy@drmalcolmanderson.net

CONSENT FOR SPECIAL CIRCUMSTANCES

CHILDREN AND ADOLESCENTS AGES 15 AND UNDER

At these ages, child clients are considered dependent minors and confidentiality belongs to the legal parent/guardian(s).  It should be explained to the child that there is a difference between privacy and confidentiality; therefore, a child can expect that their communications are kept private unless it is, in the judgment of the therapist, that parents need to be informed of a particular issue or circumstance that poses a direct threat to the safety of the minor in question. Examples might include (but are not limited to):  at risk behaviors, medical issues, family dynamics, or other situations in which the parents may be needed as a therapeutic resource.  It is my general philosophy to use a model in which parents can serve as consultants in the therapy of children fifteen years and under.

Children of divorced/separated parents:  Although these situations can be difficult and delicate, there are certain legal and ethical guidelines that I follow:

  • CONSENT FOR TREATMENT MUST BE OBTAINED FROM BOTH PARENTS UNLESS SOLE LEGAL CUSTODY IS DOCUMENTED.  I will require that an updated copy of this document be kept in my file reflecting the custodial parents control to make medical decisions on behalf of the minor.
  • Unless sole custody is established, both parents have the right to communicate with me regarding treatment issues.  I have the right to communicate with either/both parents regarding treatment issued based on my clinical judgment.  All written communication will be copied to both parents.
  • Because the child is the client, it is my job to work as an advocate for the welfare of the child.  Unresolved marital conflicts may require treatment in another therapeutic setting.


I understand the above information and/or have discussed any questions related to the above information to my satisfaction.

Please note that all name fields will also be treated as this form being digitally signed. Dr. Malcolm Anderson Ph.D. may also require this form be physically signed at the practice.

CONSENT FOR SPECIAL CIRCUMSTANCES

ADOLESCENTS 16 – 18 YEARS OLD and SOME COLLEGE STUDENTS

At these ages in the State of Georgia, confidentiality as a privilege belongs to the client.  I am aware that in most cases, children may still be legally dependent, living at home, and that parents are likely paying for therapy; nonetheless, this is the law.  THEREFORE, I MUST HAVE THE WRITTEN CONSENT OF THE CLIENT TO COMMUNICATE WITH PARENTS REGARDING ISSUES OF THEIR TREATMENT.

It is my philosophy to facilitate communication between adolescents and their families and will attempt to bring parents’ concerns into the therapy.  When I deem it clinically important, periodic family meetings will be requested.

If an adolescent client is engaged in risk taking or potentially dangerous behaviors, I operate under the same principles that apply to adult clients, working toward therapeutic remediation of the behavior(s) in question.  The dangerousness of the behavior(s) is a point of clinical judgment and in circumstances in which an adolescent refuses to cooperate with treatment recommendations to correct the behavior, it may be necessary to breach confidentiality for their protection and in rare occasions, terminate treatment.

Information received from parents via phone calls, voice mail, and/or any written communication will not generally be kept secret as this impedes the therapeutic process and relationship.

I understand the above information and/or have discussed any questions related to the above information to my satisfaction.

Please note that all name fields will also be treated as this form being digitally signed. Dr. Malcolm Anderson Ph.D. may also require this form be physically signed at the practice.

CONSENT FOR SPECIAL CIRCUMSTANCES

Family Therapy

In family therapy, the family is the client.  No information may be released without the consent of all parties to whom confidentiality belongs.  As outlined in the couples’ therapy section (above), I find it in the best interest of the therapeutic process for all parties to agree not to subpoena the therapist in the event of a legal proceeding.

Additionally, information received from either party via phone calls, voice mail, and/or any written communication will not generally be kept secret as this also impedes the therapeutic process and relationship.

I understand the above information and/or have discussed any questions related to the above information to my satisfaction.

Please note that all name fields will also be treated as this form being digitally signed. Dr. Malcolm Anderson Ph.D. may also require this form be physically signed at the practice.

Intake Information

Address
City
State
Zip
Please provide a secure cell or land phone line where a message may be confidentially left from this office.
Please provide a secure email where a message may be confidentially left from this office.

IN CASE OF EMERGENCY CONTACT

Address
City
State
Zip

PRIMARY CARE OR FAMILY PHYSICIAN

Address
City
State
Zip

OCCUPATION(S) / EMPLOYER(S)

Section

If yes, please list name and the purpose of the prescription.

Please select the "Add" option below to add more items

Please list the other people living in your home starting with the oldest.

Please list any dependents that do not live with you for whom you have joint or full custody starting with the oldest.

Who referred you or how did you come to know of my services?

Briefly list the problems that have prompted you to seek counseling at this time in order of importance.

On the scale below, with 0 being low and 10 being high, please select the number that best describes how much these concerns are interfering with your child’s life right now.

Child’s Developmental History Form

PRE / PERINATAL DEVELOPMENTAL HISTORY

EARLY DEVELOPMENT INFORMATION

Approximate weight of your child at birth
Kindly indicate below at what age (in months) your child displayed the below behaviors.

Therapy Concerns

PLEASE RATE THE AREAS OF CONCERNS USING BELOW MEASUREMENT

None = No Concern
* = Area of Concern for Me
** = Critical Area of Concern for Me

SERVICE AGREEMENT

The following statement is designed to clarify the services delivered by the provider, Malcolm E. Anderson, Ph.D., P.C.), the rates assigned for said services, and the expectations of the client/patient and the provider/therapist in this therapeutic agreement. This contract is negotiable and may be changed upon the agreement of the provider/therapist and the client/patient.

Fees for service
Fees for service are due upon delivery of services by cash, check, major credit card or money order. A receipt will be provided for your records. Accounts will be updated and you will be notified of delinquent payments. The standard fees for services are as follows:

Individual Psychotherapy: $200.00 per hourly session
Couples and /or Family sessions: $250.00 per hourly session
Intakes: A standard, non-refundable deposit fee of $25.00 will be obtained via credit card to hold any intake hour in advance.
Half-day trainings, workshops and/or presentations: $800.00
Full-day trainings, workshops and/or presentations: $2,000.00
Forensic Fees: $300.00 per hour to include: Documents prepared for court, employment, or municipal hearings, personal appearances for testimony, mediation, or educational planning or retention for ongoing legal matters. A flat retainer of $3,000.00 will be collected up front for any pre-stated legal matter for which future testimony or services may be expected.

A full fee will be charged for invalidated or returned checks. In the event that a check is returned for “insufficient funds,” the client(s) will be expected to pay for the session as well as any service penalty charged to the therapist’s account for the invalidated transaction. I reserve the right to utilize third party collectors to ensure proper payment of outstanding debts at the client’s expense.

Appointments
Clients in psychotherapy are expected to be on time for appointments. So as to be courteous to other clients awaiting appointments, a ten-minute grace period will be given before rescheduling is considered. If you are expecting to be more than ten minutes late for your appointment, please call to reschedule. If you do not call and arrive late for therapy, you will be expected to render the full payment of the missed session. If you are unable to make your scheduled appointment you must give notice of cancellation within 24 hours of the scheduled time. If you fail to give notice within this time, you will be expected to render full payment for the session missed. In the event that appointment failure occurs again, twice, the patient will be expected to provide a current credit card to the therapist prior to continuation of services.
Insurance
At this time the provider does not participate on or with any insurance panels and instead collects full fees for services when delivered. Clients with insurance coverage are expected to make full payment for services when rendered and then seek reimbursement on their own with their third party company. The therapist will provide any necessary documentation for the client to expedite this process including a record of client visits and services, an invoice of payments and account balance, a clinical diagnosis, and a summary of treatment interventions as requested from the insurance company for reimbursement.

Therapist/Provider Responsibilities
The therapist/provider will be expected to be on schedule with his appointments and contracted work assignments. A ten-minute grace period will be allowed to accompany paperwork and scheduling conflicts. In the rare event that the therapist finds it necessary to reschedule an appointment, he will try do so within a 24-hour period by phone. As client emergencies may happen there may be occasion when this early notice plan cannot be executed. If for some reason the therapist misses an appointment or fails to notify you of a cancelled appointment you will be refunded for the missed appointment.

I/We have read and understand the above information regarding the services provided by Malcolm E. Anderson, Ph.D., P.C. and agree to the negotiated statement by signing below:

Next: Booking Fee Payment

Please note that in the next section you will be asked to make a payment of $200 with your credit card to secure your first session with Dr. Malcolm Anderson. Booking will not be made and form will not be submitted without this payment being made. Please not this fee is non-refundable.

Payment Information

Credit Card Number
Expiration Date
SEC Code