New Client Information Sheet

New Client Information Sheet Please complete this questionnaire and submit to Beacon Pediatric Behavioral Health via email to [email protected] or via fax at 904.900.7732. Someone will contact you shortly to schedule a new patient appointment. Please contact us at 904.419.7792 or email us at [email protected] if you have any questions. We will do our best to respond within 48-72 hours. Thank you!

Date: Name of individual completing this paperwork: Who referred you here/How did you find out about Beacon Pediatric Behavioral Health (BPBH)?

IDENTIFYING/CONTACT INFORMATION

Client’s Name: Date of Birth: Sex: Home Phone: Cell Phone: Email: Home Address:

Father’s Name: Date of Birth: SSN# (if required for insurance): Occupation/Employer: Email: Home Phone: Cell Phone: Work Phone: Home Address (if different):

Mother’s Name: Date of Birth: SSN# (if required for insurance): Occupation/Employer: Email: Home Phone: Cell Phone: Work Phone: Home Address (if different):

I consent for BPBH to (check all that apply): Leave a message on __Mother’s home # __Father’s home # __Child’s home # __Other:______Leave a message on __Mother’s cell # __Father’s cell __Child’s cell # __Other:______Send a text to __Mother’s cell # __Father’s cell # __Child’s cell # __Other:______Email __Mother __Father __Child __Other:______

INSURANCE INFORMATION

Please be sure to review the therapist-client contract regarding restrictions, requirements, fees, etc. related to the use of insurance Do you want us to bill insurance? __Yes* (In network) __Yes* (Out of network) __No (‘Self-pay’) (*WE ARE IN NETWORK FOR: TRICARE, BCBS, VALUE OPTIONS, AND CMS TITLE XXI KIDCARE, ONLY*)

*Please provide any coverage information about co-pay, deductible, co-insurance amount, etc.:

Insurance Company: Member ID# Group # Insurance Address: Insurance Phone # Name of Policy Holder (‘PH’): PH Date of Birth: PH Phone: PH Address: PH Employer: Any secondary insurance? __Yes* __No *If Yes, please provide the same details as above:

FOR TRICARE: Please mark which type(s) of coverage you have: __Prime __Standard __Active Duty __Retired __Reserve __ECHO/Demonstration Project (ABA) __Tricare Basic Benefits (ABA) __Pilot Program (ABA)

FOR BLUE CROSS BLUE SHIELD &/OR NEW DIRECTIONS: Please mark which type(s) of coverage you have: __ HMO __PPO __ABA Therapy

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CURRENT CONCERNS/NEEDS

Please tell us about your current concerns and needs (e.g., what prompted you to contact us and what would you like to get out of services?):

Please indicate which of the following concerns you have regarding your child (mark all that apply): Noncompliance/Defiance Hyperactivity Toileting Concerns (BM/urine accidents) Tantrums/Meltdowns/Outbursts Impulsivity Sleep/Bedtime Concerns Physical Aggression Inattention/Poor Focus Eating/Mealtime Concerns Verbal Aggression Lying Daily Living Skills (dressing, hygiene, etc.) Property Destruction Stealing Completion of morning/evening routine Self-injurious Behaviors Family and/or Sibling Conflict Social Skill Deficits Elopement/Running Off or Away Depressed Mood Play Skills Deficits Academic Underachievement Adjustment to Stressors/Life Changes Communication/Language Concerns School Behavior Problems Anxiety Other:

Please indicate which services are you possibly interested in (mark all that apply): Parent education/Training in behavior modification Behavioral/ Applied Behavior Analysis (ABA) therapy (for treatment of Autism Spectrum Disorders) Cognitive Behavioral Therapy (CBT) Counseling/Individual therapy Family therapy Group therapy Consultation with child’s teacher/school staff Special education/School services advocacy and assistance Psychological/Psycho-educational/Gifted assessment (Please indicate reason for testing/ describe concerns you would like to have investigated further and/or diagnoses you would like testing for):

Other (describe):

LIVING SITUATION

Child’s parents are: __married __separated* __divorced* __widowed __never married, living together __never married, living apart* __Other:

Child primarily resides with (mark all that apply): __Biological Father __Stepfather (name/contact info): __Biological Mother __Stepmother (name/contact info): __Adoptive Father __Adoptive Mother __Other:

*If biological parents are not together, and child is under 18, are both parents aware and consenting to treatment? __Yes __No (please explain):

*If child’s biological parents are not together, please bring any legal documents regarding parental custody and legal right to medical information and decisions when you come to your first appointment* Other individuals that reside in the child’s primary household: Name Age Relationship Phone #/Email (If relevant)

If the child has any siblings or other immediate family members that are not listed above, please provide details about these individuals below: Name Age Relationship Residence Phone #/Email (If relevant)

SCHOOL/EDUCATIONAL HISTORY

Name of School: Teacher(s): Grade: Current academic or behavioral concerns related to school:

Does your child have an IEP, 504 plan, or other school services/support? __No __Yes (please describe):

MEDICAL/TREATMENT HISTORY

Name of Child’s Pediatrician and/or Medical Office: Phone Number: Significant medical history:

Current medications:

Does your child have any medical or mental health diagnoses? __No __Yes (please describe):

Please indicate if your child has ever received any of the services listed below (mark all that may apply). For any items marked, please provide the general dates during which your child received the services and the name of the agency and/or provider. SERVICE AGENCY/PROVIDER DATES Speech therapy Occupational therapy Physical therapy Applied Behavior Analysis (ABA) therapy Counseling or individual/family/group therapy Psychiatry/ Medication management Inpatient mental health hospitalization Residential short- or long-term placement Psychological/Psycho-educational evaluation Individualized Education Plan (IEP) 504 Plan Other (describe):

CRITICAL ITEMS

Please indicate if your child has ever displayed any of behaviors listed below (mark all that may apply). For any items marked, please provide a general time frame during which your child exhibited the behaviors and provide a brief description about the concern.

CONCERN DESCRIPTION DATES/TIME FRAME Threats of harm towards or harm to self Threats of harm towards or harm to others Risk-taking/dangerous behavior Cruelty towards animals Drug and/or alcohol abuse Stealing Excessive lying Playing with fire or arson Destruction of property Academic underachievement/retention Expulsion or permanent dismissal from school Binging and/or purging of food and/or anorexia Unusual or over-sexualized behaviors Psychosis/hallucinations/delusions Impairment in occupational functioning

Please indicate if your child has ever experienced any of the incidents listed below (mark all that may apply). For any items marked, please provide a general time frame during which the events occurred and provide a brief description about the events. EVENT DESCRIPTION DATES/TIME FRAME Placement in foster care/adoption Significant or frequent moves Military deployment of caregiver Parental separation or divorce Significant injury and/or impacting illness Significant/prolonged illness of a loved one Death of a loved one Involvement with the police or law Sexual abuse Physical abuse Verbal/Emotional abuse Exposure to domestic violence Involvement with Child and Family Services Experience of significant trauma

ADDITIONAL INFORMATION

If there is any additional information that you feel would be helpful for us to know, or any questions or concerns that you may have, please include the details here:

SCHEDULING NEEDS

Beacon Pediatric Behavioral Health currently provides services at two locations (Mandarin/Fruit Cove Office at12025 San Jose Blvd, Suite 2, Jacksonville, Florida 32223 and Southpoint Business Park at 6816 Southpoint Pkwy Suite 202, Jacksonville, Florida 32216). We also have several Licensed Psychologists, Board Certified Behavior Analysts and therapists on staff. While we cannot guarantee a specific date or time, we will do everything possible to provide convenient appointments. However, please be aware that we will not be able to

of 5 CLIENT/CHILD’S NAME: ______New Client Information Sheet provide you with exact information regarding our openings until we receive and review the intake paperwork. Furthermore, please be aware that initial intake appointments are often provided during morning or mid- day times due to the nature of these types of appointments; however, efforts will be made to meet your scheduling needs when possible. Please provide us with any information that may be helpful regarding scheduling in the space below.

SCHEDULING NEEDS/INFORMATION TO CONSIDER:

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