Child/Adolescent Questionnaire

Please fill out this questionnaire as completely as you can. It will help me in our work together. Please print clearly, and bring this completed form with you to our first session.

Child’s name: __________________________________ Date: _______________ Gender: _______ Age: _____                                 Grade in school: _______ Birth date: _______ Address: ______________________________________________________________ City: __________________________ State: __________ Zip code: ____________ Who referred you to Dr. Ronfeldt? ______________________________________                                                                                                                           Presenting Problem

What is the main problem for which you are seeking help? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________                                                                             How long has this been a problem for your child? _______________________________________________________________________ _______________________________________________________________________                                                                              Why are you seeking help at this time? ____________________________________

_______________________________________________________________________                                                                             

What, in your opinion, is the major cause(s) of your child’s difficulties? _____________________________________________________________________ _____________________________________________________________________                                                                              Other factors/circumstances you feel are notable at this time: _____________________________________________________________________ _____________________________________________________________________                                                                             What are your goals for therapy? _______________________________________ _____________________________________________________________________

Has your child been seen previously for psychological or psychiatric consultation or treatment? ___Yes  ___No                             If yes, please provide name of professional, dates of service, location of services, and reason for services.

_____________________________________________________________________ _____________________________________________________________________

Have you consulted any other professionals (e.g., occupational therapist or speech therapist) about your child’s difficulties or had any testing completed (e.g., neuropsychological testing, or educational testing)? ___Yes  ___No                                              If yes, please provide name of professional, dates of service, location of services, and reason for services.

_____________________________________________________________________ _____________________________________________________________________

How would you describe your child as a person? (Please include child’s strengths and weaknesses.)

_____________________________________________________________________ _____________________________________________________________________

Family Information

Parent’s name: _____________________________ Ethnic Identity: ________________ Occupation: ____________________

Home telephone #: ____________________ OK to call & leave message?: Y N                                                                                 Cell phone #: __________________________ OK to call & leave message?: Y N                                                                             Work phone #: _________________________ OK to call & leave message?: Y N                                                                         Highest grade completed _______________ Employer: ______________________________                                                               

Parent’s name: _________________________ Ethnic Identity: _________________ Occupation: ____________________                  Home telephone #: ____________________ OK to call & leave message?: Y N                                                                                 Cell phone #: __________________________ OK to call & leave message?: Y N                                                                             Work phone #: _________________________ OK to call & leave message?: Y N                                                                         Highest grade completed ______________           Employer: ______________________________

Parents are: ___married, ___ separated, ___divorced: custody is with ___________                                                                  Remarried (___Mother ____Father ___Both)
___Deceased (___Mother ___Father ___Both)

Please provide dates for above events:

_____________________________________________________________________________

Child is your: ___biological child ___step child ___foster child ___adopted child (child’s age at time of adoption: )

List all the people living in your child’s home:
Name Relationship Birth date Occupation

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

Do any family members have any physical or emotional health problems? ___Yes  ___NO                                                                If yes, explain briefly
Father? __________________________________________________________                                                                               
Mother? _________________________________________________________                                                                               Siblings? _________________________________________________________                                                                             Mother’s family? _________________________________________________                                                                                  Father’s family? __________________________________________________                                                                                        Are there any other family concerns? ________________________________ _________________________________________________________________

Has child ever experienced any of the following? (Please mark all that apply) ___Physical abuse ___Sexual abuse              ___Alcohol abuse ___Drug abuse ___Suicide attempt ___Involvement with the Police

If yes, briefly explain circumstances (include approximate dates and age of the child at time of occurrence):

________________________________________________________________ ________________________________________________________________

Are you involved in any current or pending civil or criminal litigation(s), lawsuit(s), or divorce/custody dispute(s)?                            If yes, please explain current circumstances:

________________________________________________________________ ________________________________________________________________

Describe briefly any special interests, hobbies, and recreational activities in which family members participate.

________________________________________________________________ ________________________________________________________________

Pregnancy/Birth History

Were there any complications with the pregnancy or any known physical/emotional health problems of mother during pregnancy?

________________________________________________________________ ________________________________________________________________

Did the mother take any medications or use any substances, ie, tobacco, alcohol, or other drugs during the pregnancy? If yes, please explain briefly:

________________________________________________________________

________________________________________________________________

Was your child premature? Y N If yes, how many weeks? _______ What was the birth weight? ____lbs. ____oz.

Were there any complications with the delivery? If yes, please explain briefly: ________________________________________________________________ ________________________________________________________________                                                                   Developmental History

Age at which child: ____ crawled ____took first steps ____spoke first words ____spoke in full sentences ____ day bladder trained ____night bladder trained ____bowel trained ____onset of puberty

How does your child get along with other children and his/her siblings? ________________________________________________________________ ________________________________________________________________

Do you feel that your child has been developmentally on target? Please comment on skills including motor, verbal, social, and physical development:

________________________________________________________________ ________________________________________________________________

Child Health Information:

Check or write-in all health problems your child has had or has now. _____High fevers _____Dental Problems ____Pneumonia ____Weight Problems ___Chronic Pain ___Allergies ___Encephalitis ___Skin Problems
___Meningitis ___Asthma ___Seizures ___Headaches
___Unconsciousness ___Stomach Problems ___Concussions ___Accident Prone ___Head Injury ___Anemia ___Fainting ___High/Low Blood Pressure ___Dizziness ___Sinus Problems ___Tonsils Out ___Heart Problems
___Vision Problems ____Hyperactivity ___Repetitive/stereotyped movements ___Impulsivity ___Hearing Problems ___Nail biting ___Earaches
___Learning disorder ___Sleep problems ____Other (describe): _____________

If yes to any health problems, please explain briefly: ________________________________________________________________ ________________________________________________________________

Has your child ever been hospitalized? If yes, please explain briefly: ________________________________________________________________ ________________________________________________________________

Has you child had any major accidents that required medical care?

________________________________________________________________

________________________________________________________________

List any medications your child has taken or is currently taking as well as dates of and reasons for medications.

________________________________________________________________ ________________________________________________________________                                                                                  Primary Care Physician (name, address, phone #): ___________________ ________________________________________________________________

Educational History

Current school and address: ______________________________________ ________________________________________________________________

Has your child skipped or repeated a grade? Yes No                                                                                                                       Does your child miss school on a regular basis? Yes No                                                                                                                     Is your child unmotivated for school? Yes No                                                                                                                                   Has your child ever been suspended or expelled from school? Yes No                                                                                        Does your child have any specific learning difficulties? Yes No                                                                                                    Does your child require any special academic help? Yes No                                                                                                             If yes to any questions, please explain briefly: ______________________ ________________________________________________________________

Additional Remarks:

Feel free to provide any additional information you would for like me to know about your child.

________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Would you like me to provide you with monthly receipts for your payments to me? ___Yes ___NO                                                    If yes, I typically provide receipts at the end of the month.

 

Consent for E-mail and Text Communication

You* and Dr. Ronfeldt may elect to communicate via e-mail or text. If you do so, it is important that you understand that encrypted email messaging through hushmail is always preferred to unsecured, non-encrypted messaging through hushmail, regular e-mail, or text messages. If you choose to communicate with Dr. Ronfeldt via unsecured e-mail or text messaging, you understand that these messages are not private, and that Dr. Ronfeldt will make every effort to keep these communications confidential but that she cannot guarantee the confidentiality of them. E-mail and text messages also become part of the clinical record and are subject to discovery in legal proceedings.

If you choose to communicate with Dr. Ronfeldt via secure or insecure e-mail or text communications, please be aware that she is obtaining information only from e-mail or text messages and as a result, is making clinical judgments on the basis of limited and imperfect information. In addition, Dr. Ronfeldt may not receive e-mail or texts in a timely fashion. So, if you are experiencing an emergency or crisis and need a timely response, please call her on the telephone.

* Parents and guardians of under aged patients, the terms “you” and “your” is intended to include your child throughout this document.

I have read and understand, accept, and agree to the contents of this document

______________________________________ Print Name

______________________________________ Signature

______________________________________ Date

 

Notice of Privacy Practices

(Health Insurance Portability and Accountability Act Provisions)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The protection of your* health information is very important. As a mental health professional, I recognize that many of the things we discuss are sensitive, and because of this, it is important that you are aware of how this information is used and may be revealed. This document contains a description about how your protected health information (PHI) is used and sometimes disclosed. As a healthcare professional covered under the Health Insurance Portability and Accountability Act (HIPAA), I am required to give you this notice and to abide by its terms.

In general, the communications between you and I are confidential and protected by law and I can only release your PHI with your permission, or under certain circumstances. This document and other intake documents discuss those circumstances. When I make a disclosure, I will always try to limit the information that I reveal. In general, I will try to disclose only the amount necessary.

Every time you visit me, a record of your visit will be added to your clinical record. Your clinical record contains information, ie, dates of and notes about our meetings, diagnoses, functional status, medications, history, therapeutic goals, treatment plan and progress, test results, billing information, and any information that you have asked to be forwarded by other providers.

* Parents and guardians of under aged patients, the terms “you” and “your” is intended to include your child throughout this document.

How I May Use and Disclose Your PHI

I may use and disclose your PHI for certain treatment, payment, and health care operations. In general, I will ask for your consent or authorization for these uses and disclosures. An example of a disclosure for treatment purposes is one where I discuss your treatment/evaluation with your physician to coordinate our services. An example of a disclosure for payment is where I discuss your case with your health insurance carrier to determine if you are eligible for coverage. An example of a disclosure for health care operations, is where I disclose information for the purposes of conducting quality assessment or quality improvement functions. I may also contract with agencies to attend to business aspects on an as-needed or regular basis. In these cases, there will be a written contract in place with the agencies requiring that they maintain the security of your PHI in compliance with the rules of HIPAA. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract.

I can also use and disclose your PHI without your consent or authorization in the following circumstances:

Abuse and Threat to Health or Safety: If I suspect that a child, elderly person, or dependent adult is being abused or neglected, if I believe that you are in danger of harming yourself or someone else, or if you are unable to care for yourself, I may be required to use and disclose your PHI.

Health Oversight: It is possible that I might have to disclose your PHI to health oversight agencies for purposes of legally authorized health oversight activities. For example, the Department of Health and Human Services might want to review how I comply with the regulations of HIPAA. In such a case, your personal health information could be revealed in order to provide evidence of compliance.

Judicial or Administrative Proceedings: I may have to disclose your PHI in response to a court or administrative order, or in response to a subpoena.

Required by Law: I may have to disclose your PHI without your authorization if state or federal law requires it.

Law Enforcement: I may be required to disclose PHI at the request of a law enforcement official or for law enforcement purposes.

Worker’s Compensation: If your treatment is being paid for through a worker’s compensation claim, then I will likely be required to disclose your PHI.

Other Sections of the Privacy Rule or Confidentiality Law: I may have to use and disclose your PHI without your consent or authorization in other cases, ie, to a coroner or medical examiner, for research, for public health reasons, for cadervic organ or eye or tissue donation, and for special government functions, ie military, national security, and presidential protective services.

When I make disclosures for these purposes, I will disclose only the information necessary. Any additional disclosures will be made only with your written authorization and can be revoked at any time by submitting a request in writing. After you revoke your authorization, I will no longer use or disclose your PHI for the reasons described in the authorization.

Your Rights Regarding Your PHI

You have the following rights regarding your PHI:

The right to inspect and obtain a copy of your clinical record

You may request in writing to inspect or obtain a copy of your clinical record. Reviewing the record is best done during a professional consultation in order to clarify any questions that you might have at the time. You may be charged a nominal fee for accessing and photocopying the record. I may deny your request but you may have the right to appeal this decision. Upon your request, I will discuss with you the details of the request and denial process.

The right to request a correction or add an addendum to your clinical record

If you believe that there is an inaccuracy in your clinical record or if you believe that the record is incomplete, you may request an amendment to your PHI in writing. I may

deny your request. On your request, I will discuss with you the details of the amendment process.

The right to an accounting of certain disclosures

You have the right to receive from me an accounting of disclosures of your PHI with certain exceptions. The exceptions include disclosures that were made for the purposes of treatment, payment and health care operations, or that were authorized by you. This accounting must extend back for a period of six years.

The right to request restrictions on how your information is used

You have the right to request restrictions on certain uses or disclosures of your psychological information. These requests must be in writing and in some cases, they may be denied. If I agree to these restrictions, I must abide by our agreement except when otherwise required by law or in emergencies.

The right to request confidential communications

You have the right to make reasonable requests that your therapist communicate with you about your treatment in a certain way or at a certain location. For example, you may prefer to be contacted at work instead of at home to schedule or cancel an appointment, or you may wish to receive billing statements at a post office box rather than your home address.

The right to receive a paper copy of this notice upon request

If you originally received an electronic copy of this document, you have the right to request a paper copy of this Notice of Privacy Practices.

The right to restrict disclosures when you have paid for your care out-of-pocket

You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.

The right to be notified if there is a breach of your unsecured PHI

You have a right to be notified if: a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; b) that PHI has not been encrypted to government standards; and c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

Questions, Complaints, and Changes to Notice

If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me to discuss your questions or concerns. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I will not retaliate against you for exercising your right to file a complaint.

This notice will go into effect on April 1, 2015. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by giving you a copy and by posting it on my website.

 

PSYCHOLOGICAL SERVICES AND POLICIES

This document contains important information about my professional services and business policies. Please read it carefully and let me know if you* have any questions so that we can discuss them.

* Parents and guardians of under aged patients, the terms “you” and “your” is intended to include your child throughout this document.

PSYCHOLOGICAL SERVICES

During our initial session(s), I will offer you some first impressions of your difficulties and treatment options. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my services or policies, we should discuss them whenever they arise. There are often various treatment options, ie, various individual psychotherapy approaches, group therapy, or medication treatment. I may recommend or you may wish to explore treatment with a therapist other than me, to consult with another professional, or to ask for a second opinion. I will provide you with a rationale for any of my recommendations and help with referrals if needed.

Psychotherapy is not easily described in general statements. It varies depending on the approach of the therapist and the particular problems you bring forward. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings, ie, sadness, anger, anxiety, or frustration. At times, treatment may even result in worsening of symptoms or changes that were not originally intended. On the other hand, psychotherapy has been shown to have benefits for people who go through it. There are no guarantees of what you will experience.

If I recommend and you agree, I will provide psychotherapy for you. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. You will also be asked to outline treatment goals with me. Treatment decisions will be made collaboratively, between you and I. I may recommend exposure therapy which involves deliberately exposing you to situations that evoke anxiety or other distressing emotions so that you can learn new responses. Exposure therapy may even involve leaving my office and going out into public situations. If at any point you are unhappy about the progress, process or outcome of your treatment, please discuss this with me so that we may attempt to resolve any difficulties and arrive at a treatment plan that better meets your needs.

MEETINGS

If psychotherapy is begun, I will usually schedule one 50-minute session per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, I reserve that time for you. Consequently, I require 48 hours, 2 days, notice if you need to cancel or re-schedule an appointment. This typically allows me enough time to try to fill your cancelled appointment. I usually charge for a missed appointment if you give me less than 48 hours notice and I am unable to fill your appointment time unless we both agree that you were unable to attend due to unanticipated circumstances beyond your control. Please be aware that insurance companies doe not typically reimburse for missed appointments.

PROFESSIONAL FEES

My fee for a 50 minute session is $170. In addition to weekly appointments, I may charge this same rate (pro-rated according to length) for other professional services you may need. Other services include telephone conversations with you or consulting professionals, attendance at meetings with other professionals, transportation time to and from meetings outside of my office, writing letters or treatment summaries, or the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, my fee for these services is higher than my usual fee. Upon request, we can discuss legal fees.

BILLING AND PAYMENTS

You will be expected to pay for each session at the time it is held. Other payment schedules and payment for other professional services will be agreed upon when they are requested. There is a $20 fee for any returned check. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. If legal action is necessary, its costs will be included in the claim.

I am not a preferred provider on any insurance plans. If your mental health coverage will reimburse for all or part of my services, I ask that you pay me directly at each of our sessions and submit the bills to the insurance company yourself. If you request it, I will provide you with a billing statement once per month that will include information that insurance requires, ie, diagnosis code(s), clinical services code(s), dates of service, and payments made. Please make sure to find out exactly what mental health coverage your insurance policy provides. In some cases, insurance companies will require that I send them information from your records. Upon your request, I will provide insurance with the minimum information necessary. Please be aware that I have no control over or knowledge of what insurance companies do with the information I submit to them or who has access to this information.

CONTACTING ME

Please note I am often not immediately available by telephone. While I am usually in my office from 9am–7pm on Mondays, Tuesday, and Thursdays, and from 1-5pm on Fridays, I will not answer business calls when I am with a patient. When I am

unavailable, my telephone is answered by voice mail that I monitor frequently Monday-Friday during office hours. During these hours, I will make every effort to return your phone call within 24 hours. I do not routinely answer phone calls or check voice mails outside of my regular business hours, ie, after 7pm on weekdays, weekends, vacations, business trips, and holidays. So, if you call me outside of my regular business hours, my return call may take longer than 24 hours. If an urgent matter arises and you are unable to reach me and feel that you cannot wait for my return call or it arises outside of my regular business hours, please contact your primary care physician or psychiatrist, go to your nearest emergency room, or call 911. If I am unreachable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep treatment records for each patient. Your clinical record may include a description of your concerns and symptoms, diagnoses, medications, records from previous providers, history, treatment goals and progress, summaries of our sessions as well as billing information, consents or authorizations, assessments, or other forms related to your treatment. My notations will either be handwritten and stored in a locked file cabinet, or they will be typed and stored in an encrypted file on my computer and backed up on an encrypted flash drive that is stored in a locked file cabinet.

If you request it in writing, you may examine and/or receive a copy of your clinical record except in unusual circumstances, ie, the disclosure would physically endanger you and/or others, your records make reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person, or where information has been supplied to me confidentially by others. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. You may be charged a fee for accessing and photocopying the record. If I refuse your request for access to your records, you have a right of review (except for information supplied to me confidentially by others) which I will discuss with you upon request.

BREACH NOTIFICATION

I will do my best to keep all of your personal health information (PHI) secure. However, if I become aware of or suspect a breach of your PHI, I will conduct a risk assessment of the breach, ie, the nature and extent of PHI involved, to whom the PHI may have been disclosed, whether the PHI was actually acquired or viewed, the extent to which the risk to the PHI has been mitigated. I will keep a written record of this assessment. Unless I determine that there is a low probability that PHI has been compromised, I will give notice of the breach to my clients who are affected by the breach and to HHS (Health and Human Services). The risk assessment can be done by a business associate if it was involved in the breach. While the business associate will conduct a risk assessment of a breach of PHI in its control, I will provide any required notice to my patients and HHS. After any breach, particularly one that requires notice, I will re-assess my privacy and security practices to determine what changes should be made to prevent the recurrence of such breaches.

MINORS

If you are under eighteen years of age and not emancipated, please be aware that the law allows your parents the right to examine your treatment records unless I believe it would be harmful to you and your treatment. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from parents that they consent to give up access to the records. I will provide them with general information about our work together, ie, treatment attendance, recommendations, goals, diagnoses, plan, and progress as well as information that you request that I share. If I feel there is a high risk that you are in danger of harm or in danger of harming someone else, I will notify your parents of my concern. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss.

CONFIDENTIALITY

In general, the privacy of all communications between a patient and a psychologist is protected by law and I can only disclose information about our work to others with your permission with some exceptions, ie, if I suspect that a child, elderly person, or dependent adult is being abused or neglected; if I believe that you are in danger of harming yourself or someone else; if you are unable to care for yourself; if I am court ordered to release information as part of a legal proceeding; or as otherwise required by law. I may also be required to to disclose your PHI for other reasons (see my Notice of Privacy Practices), ie, for health oversight activities, law enforcement, worker’s compensation, special government functions, research, public health reasons, organ donation, or to a coroner or medical examiner. If any of these situations occur, I will make every effort to fully discuss it with you before taking any action.

I may occasionally find it helpful to consult with other professionals about a treatment case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant(s) are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I may also contract with agencies to attend to business aspects on an as-needed or regular basis. In these cases, there will be a written contract in place with the agencies requiring that they maintain the security of your information, in compliance with the rules of HIPAA. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract.

While this written summary of some of the exceptions to confidentiality and my Notice of Privacy Practices should prove helpful in informing you about potential problems, they are not exhaustive and it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.

RECORD PRIVACY ARRANGEMENT

I may sublet my office to other people when I am not in the office. If I do so, my practice will not be affiliated with theirs in any way, I will simply be co-leasing my office space. I will be completely independent in providing you with clinical services and I alone will be fully responsible for those services. My professional records will be

separately maintained and will not be accessible to anyone with whom I co-lease my office space unless you authorize me to do so.

ENDING TREATMENT

You have the right to terminate therapy at any time. I recommend that you discuss with me your plans to terminate before taking any action so that I can offer any recommendations, provide you with referrals, and discuss any potential consequences of ending treatment at that time. If you still want to terminate therapy, a final session is strongly recommended for closure of our work together.

I have read and understood the information in this document and have had my questions answered to my satisfaction. I accept, understand, and agree to abide by the contents and terms of this agreement. I consent to participate in the evaluation and treatment provided by Dr. Ronfeldt.

_______________________________Client Name (printed)                                              _________________________________________  Client Signature Date

If client is under 18 years old, I will need the signature of the child’s custodial parents

_______________________________ Legal Guardian Name (printed)

_________________________________________ Legal Guardian Signature & Date

_______________________________ Legal Guardian Name (printed)

_________________________________________ Legal Guardian Signature & Date

I also certify that I have received a copy of, read, and agree to the terms of Dr. Ronfeldt’s Notice of Privacy Practices for Protected Health Information

_______________________________Client Name (printed)                                              _________________________________________  Client Signature & Date

If client is under 18 years old, I will need the signature of the child’s custodial parents

_______________________________ Legal Guardian Name (printed)

_________________________________________ Legal Guardian Signature & Date

_______________________________ Legal Guardian Name (printed)

_________________________________________ Legal Guardian Signature & Date