Child Intake Paperwork () - Northwest Neurobehavioral Health

Attention Please!
A biological parent or legal guardian must complete and sign all patient
paperwork. In addition, a biological parent or legal guardian (with proof of
guardianship) must accompany the client to all appointments.
If a biological parent or legal guardian is unable to be present we MUST have a
release of information form for the caregiver bringing the client. THIS FORM
MUST BE FILLED OUT AND SIGNED BY A BIOLOGICAL PARENT OR LEGAL
GUARDIAN.
In the event we do not have a valid release or proof of guardianship the
appointment WILL be rescheduled.
Please call if you have any questions regarding the above statements.
2076 S. Eagle Rd. Meridian, ID 83642 Phone: (208)955-7333 Fax: (208)955-7330
PROTECTED HEALTH INFORMATION RELEASE ACCESS REQUEST FORM
I hereby authorize Northwest Neurobehavioral Health, LLC to disclose AND/OR [circle one] receive records for:
Patient/Client name: __________________________________________________ DOB: _____________________
From/To: ___________________________________________________________ Phone: ____________________
Address: ___________________________________________________________ Fax: ______________________
The following information: [Check all that apply]
_____ Speech Evaluation
____ Psychological Evaluation
____ Presence/Participation in Treatment
_____ OT Evaluation
____ Neuropsychological Evaluation
_____ Intake Evaluation/CDA
_____ Physician Note
____ ASD Clinic Evaluation
_____ Other ______________________
_____ Treatment Plan (s)
Conditions- I understand that Northwest Neurobehavioral Health, LLC will not condition my treatment on whether I give
authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have
consequences including, but not limited to impacting the outcome of coordinated care.
Please Note- Medical records may contain sensitive information including, but not limited to: Alcohol, Drugs, Mental Health,
HIV/AIDS, and Sexually Transmitted Diseases.
Purpose- The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to
treatment and when appropriate, coordinate treatment services.
Revocation- I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to
Northwest Neurobehavioral Health, LLC at 2076 S. Eagle Rd. Meridian, Id. 83642. I further understand that a revocation of the
authorization is not effective to the extent that action has already been taken in reliance on the authorization.
Form of Disclosure- Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the
right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with
applicable law, including, but not limited to, verbally, in paper format or electronically.
Redisclosure- I understand that there is the potential that the protected health information that is disclosed pursuant to this
authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA
privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections.
Expiration- Unless sooner revoked, this authorization expires on the following date: ________________, or as otherwise
indicated:________________________________________________________________.
________________________________________________________________________________________________________
Signature of Patient/Client (If 14+ Years of Age)
Date
Signature of Parent, Guardian or Personal Representative
Date
(If you are signing as a personal representative of an individual, please describe your authority to act for this individual, for
example; power of attorney, healthcare surrogate, etc.)
www.nnhidaho.com
2076 South Eagle Road, Meridian, Idaho 83642
Phone: (208) 955-7333 Fax: (208) 955-7330
The information disclosed to you may be from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules and state law prohibit you from making any further disclosure of this information unless further disclosure is
expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal
rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse individual. Authorization for Release PHI – HMO 1026041.doc
NORTHWEST NEUROBEHAVIORAL HEALTH, LLC
Date: ____________
PATIENT REGISTRATION
PLEASE PRINT AND COMPLETE ALL ENTRIES
PATIENT NAME (LAST -- FIRST -- MIDDLE INITIAL)
ADDRESS
CITY, STATE
ZIP
PATIENT DATE OF BIRTH
PATIENT SSN
PATIENT/PARENT EMPLOYER NAME
Gender
 Male
CELL PHONE
MARITAL STATUS
 Single  Married  Other______________
 Female
PATIENT/PARENT EMPLOYER ADDRESS (STREET - CITY - STATE - ZIP)
NAME (FIRST -- LAST -- MIDDLE INITIAL)
EMPLOYER PHONE
RELATIONSHIP TO PATIENT: parent guardian other (explain)
GUARDIAN INFORMATION IF PATIENT IS MINOR
HOME PHONE
HOME PHONE
ADDRESS (if different from patient)
CELL PHONE
EMAIL ADDRESS
WORK PHONE
EMPLOYER
INSURANCE INFORMATION
PRIMARY INSURANCE NAME
GROUP NUMBER
SUBSCRIBER NAME
ID NUMBER
SECONDARY INSURANCE NAME
GROUP NUMBER
SUBSCRIBER DATE OF BIRTH
CO-PAY AMOUNT
SUBSCRIBER NAME
ID NUMBER
SUBSCRIBER DATE OF BIRTH
CO-PAY AMOUNT
PRIMARY DOCTOR OR FAMILY DOCTOR- NAME/NUMBER/FAX
PHARMACY- NAME/NUMBER/FAX
EMERGENCY CONTACT
RELATIONSHIP
PHONE NUMBER
ASSIGNMENT AND RELEASE : I hereby authorize Northwest Neurobehavioral Health, LLC to release any medical information
necessary to process claims and to apply for benefits on my behalf for covered services furnished to me by Northwest
Neurobehavioral Health. I certify that the insurance information supplied is correct and understand I will be responsible for any
services not covered by insurance. I also understand that any co-pay I have with my insurance plan is due at the time of service.
SIGNATURE (Patient or, if minor Signature of parent or guardian)
DATE
We are required by Federal health care programs to request this information as a part of the demographic data they collect. Individuals are asked to indicate
one or more races and ethnicity that apply from among the following or you may decline to specify.
Ethnicity:
Hispanic
Race:
Decline
Latino
Not Hispanic
Decline
 American Indian or
 Asian
Alaskan Native
 Black or
 Native Hawaiian or
African American
Other Pacific Islander
 White
RELEASE OF INFORMATION
I understand that:
●
Once Northwest Neurobehavioral Health, LLC discloses my health information by my request, it cannot guarantee that the Recipient will not re-disclose
my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state laws
governing the use and disclosure of my health information.
●
I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the
Federal Privacy Rule 45 CFR (164.524).
●
My records are protected and cannot be disclosed without written permission
●
This authorization will remain in effect until written notice of revocation to the Medical Record Department is received.
SIGNATURE OF PATIENT OR LEGAL REPRESENTATIVE
DATE
IF SIGNED BY LEGAL REPRESENTATIVE, RELATIONSHIP TO PATIENT
SIGNATURE OF WITNESS (Optional):
EMAIL
www.nnhidaho.com 2076 South Eagle Road, Meridian, Idaho 83642 * Phone: (208) 955-7333 * Fax: (208) 955-7330
Child’s Name
Gender with which child identifies
 M
Child’s Age
Child’s DOB
Person Completing Form
Residence of Child
 Biological/Step Parents
 Other
Date
 F

Referred by
Relationship to Child
 Adoptive Parents
 Foster Parents
 PCS Home
Presenting Problems
Please describe why you are seeking services for this child:
When did you first notice the problem?
Has this problem affected his/her functioning?
At home:
 Severe  Substantial  Moderate  Mild  Minimal
At school:
 Severe  Substantial  Moderate  Mild  Minimal
Community:
 Severe  Substantial  Moderate  Mild  Minimal
(Please explain)
Is the child experiencing problems in any of the following areas?
 Aggressive behavior
 Anxiety/Worry
 Attention span
 Changes in eating habits
 Changes in sleeping habits/Problems sleeping
 Cruelty to animals
 Destroying property
 Disobedience
 Distorted body image
 Fears
 Headaches/Stomachaches
 Hearing/Seeing strange things
 Hopelessness/Helplessness/Worthlessness
 Hyperactivity
 Intrusive/Recurrent memories
 Irritability
 Lack of interest in things
 Language impairments
 Lying/Stealing
 Low self-esteem
 Nightmares
 Obsessive thoughts/Compulsive Behaviors
www.nnhidaho.com
2076 South Eagle Road, Meridian, Idaho 83642  Phone: (208) 955-7333  Fax: (208) 955-7330
Page 1 of 10
Presenting Problems (cont’d)
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Paranoia
Racing thoughts
Restlessness
Sadness/Crying
Sexual behavior
Social relationships/Anxiety
Suicidal talk/Self harm behaviors
Tantrums
Toileting (wetting/soiling)
Withdrawal/Isolating behaviors
Family Information
Individuals living in the household:
Name
Age
Relationship to Child
Relationship with Child
Parent’s educational background and occupation:
Mother
Father
Has the child experienced any of the following stressful events? (Please list child’s age at the time of event)
Age
Death of a family member or significant (Specify:

Divorce or separation of parents (When:
, Custody arrangement/visitation and frequency:

Name and location of non-custodial parent:
Foster care, or other out-of-home placement:

Frequent moves (How many times)?
Locations?

Incarceration of a parent (Details):

Long-term physical illness of a family member

Other (Please list any additional stressful events the child or family has recently experienced):

Are there marital or parenting struggles?
)
 Yes  No (Please explain)
Family’s economic/financial status:
Monthly income sources and amounts, if known:
 Employment wages/salary $
 Unemployment
 Welfare benefits
$
 Food stamps
 Housing assistance
$
 Family support
 Other Specify: $
$
$
$
 SSD
$
 SSI
$
 Other Specify: $
Is income adequate for current needs?  Yes  No
www.nnhidaho.com
2076 South Eagle Road, Meridian, Idaho 83642  Phone: (208) 955-7333  Fax: (208) 955-7330
Page 2 of 10
Family Information (cont’d)
Housing Issues:
 Safe/stable
 Unsafe/inadequate  Temporary
 Conflict with neighbors/landlord  None
 Other
Future living plans:
 Foster care
Has the child ever been involved in any of the following services? (Please list child’s age at the time of event)
 Child Protective Services
 Children’s Mental Health
 Probation/Juvenile Probation/Detention
 Boys and Girls Club
 Youth Services
 Head Start
 Early Intervention Services (ages 0-3)/Developmental Preschool
Social History
Is the child the respondent’s biological child?  Yes  No
If no, at what age did he/she come into their care?
Has the child been adopted?  Yes  No
Age at adoption?
Is there any contact with the biological parents?  Yes  No
If yes, please describe:
Where was the child born and raised?
Does the child have quality relationships with peers?  Yes  No
(Please explain)
Child’s sexual history (if applicable):
Sources of support include:  Parent(s)  Guardian  Sibling(s)  Other relative(s)  Friend(s)
 Other
Child’s closest personal support:
Name
Address
Level of support is:
 Good
If less than adequate, explain:
Social/Environmental Issues:
 Social isolation/Withdrawal
 Family conflict
 Lack of services
 Volatile living environment
 Other, explain:
Phone
 Adequate
 Marginal
 Negative peer influences
 Conflict with caregivers
 Lacks knowledge of services
 None
 Minimal
 None
Relationship
 None
 Lifestyle change
 Lacks transportation
 Lacks knowledge of illness/Disability
Is there anything that would prevent the child from attending sessions regularly?  Yes  No  Unknown
(Please explain)
www.nnhidaho.com
2076 South Eagle Road, Meridian, Idaho 83642  Phone: (208) 955-7333  Fax: (208) 955-7330
Page 3 of 10
Social History (cont’d)
Does the child have consistently reliable transportation?  Yes  No  Unknown
Ethnic, Cultural, and Religious information may be helpful in addressing counseling issues.
The following information is optional. Please mark the appropriate line(s).
 I choose to provide this information
 I choose not to provide this information
Do you have a religious or spiritual identity?  Yes  No  Unknown
If yes, what is that preference?
What is the race of the child?
 Euro-Western or White  American Indian or Alaska Native  Hispanic or Latino
 Native Hawaiian
 Black or African American
 Asian American or Asian
 Unknown
 Other
Has the child ever experienced problems related to race, religion, or culture?  Yes
 No
(Please explain):
 Unknown
Pleas describe your child’s temperament and activity level as an infant:  Overly calm/inactive  Calm/reasonably
active  Very active/overly active  Other (Please explain) __________________________________________
When young, how did your child interact with other children?  Shy/inhibited  Reasonably outgoing/enjoyed
interacting with others  Overly outgoing/problematic  Other (Please explain) ___________________________
Does your child have any current social difficulties?  Yes  No
If yes, does your child have trouble with  Making new friends  Keeping friendships  Approaching other
children  Violating personal space  Disinterest in social relationships  Other (Please explain):
_________________________________________________________________________________________
Does your child have a current or past history of:
 Difficulty with nonverbal behaviors (i.e. eye-contact, making facial expressions which do not fit the context, using
gestures to regulate social interactions)
 Failure to develop peer relationships to an appropriate level
 Difficulty with social/emotional reciprocity (i.e. playing games involving back and forth play, recognizing how
others are feeling, understanding how their actions effect others)
 Trouble sustaining back and forth conversations outside areas of interests
 Significant stereotyped or repetitive use of language (i.e. repeating quotes from movies, repeating same phrase
over and over, echoing the response of others, making odd or unusual sounds)
 Fixated interests in a specific area; if yes, what is the area of interest _____________________________________
 Stereotyped of repetitive motor behaviors (i.e. hand/finger flicking, arm flapping, spinning, rocking back and forth)
Mental Health History
Does your child have any history of emotional difficulites or previous diagnoses? Including:
Depression
Anxiety/Panic Attacks
Mania
ADHD
Cognitive Impairment
Autism Spectrum Disorder/Asperger’s/PDD-NOS
Substance Abuse
PTSD
Obsessive-Compulsive Disorder
Schizophrenia
Has the child or immediate family member ever been to counseling or seen a psychiatrist?
 Yes  No  Unknown
Treatment Received
Individual
Date(s)
Diagnosis
(inpatient, outpatient, residential, etc) Response
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2076 South Eagle Road, Meridian, Idaho 83642  Phone: (208) 955-7333  Fax: (208) 955-7330
Page 4 of 10
Has the child ever expressed suicidal thoughts or attempted suicide?  Yes  No  Unknown
(Please explain)
Has the child or any other family member ever been abused or neglected?  Yes  No  Unknown
Individual Abused Type of Abuse
Date(s)
Action Taken
Does the child use drugs or alcohol (including tobacco)?  Yes  No  Unknown
Please list type, amount, frequency, and dates (first use, last use):
Name
Amount
Frequency
Date(s)
Mental Health History (cont’d)
Family history of mental/medical illness: (Please specify who and when first diagnosed)
 ADHD
 Anxiety/Panic Attacks
 Alcohol/Drug Abuse
 Autism/Asperger’s/Pervasive Developmental Disorder
 Bipolar
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Depression
Learning Disability
Intellectual Disability
“Nervous Breakdown”
Obsessive Compulsive Disorder (OCD)
Panic Disorder
Post-Traumatic Stress Disorder (PTSD)
Psychiatric Hospitalizations
Schizophrenia
Suicide
Cancer (Type)
Diabetes/High Blood-Pressure
Heart or Lung Problems
Immunological Disorders (Lupus, Inflammatory Bowel Disease)
Migraines
Seizures
Thyroid
Other
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2076 South Eagle Road, Meridian, Idaho 83642  Phone: (208) 955-7333  Fax: (208) 955-7330
Page 5 of 10
Developmental History
Mother’s age during pregnancy:
Length of pregnancy:
Any previous pregnancies (number)?
Any previous miscarriages (number)?
Did mother receive regular prenatal care?  Yes  No When did prenatal care begin?
Did mother have any ultrasounds or amniocentesis?
 Yes  No
If yes, please describe the reason:
Did mother use prenatal vitamins?  Yes  No
How much weight did mother gain?
Did the mother experience any of the following during pregnancy? (Please indicate # of months into pregnancy)
 Accidents or injuries
 Emotional stress
 Illness or infection
 Bleeding
 Fevers
 Induced labor
 Rh/Blood incompatibilities
 High blood pressure/swelling
 Toxemia
 Diabetes
 Hospitalizations
 Diet Problems
 Other (Please explain)
Did the mother use any drugs, alcohol, and/or medications during pregnancy (including nicotine, prescription and
over the counter drugs)?  Yes  No  Unknown
Drug Abused or suspected abuse:  Alcohol  Tobacco  Marijuana  Methamphetamine  Cocaine
 Prescription Medications  Other Drugs
If known, please list the frequency and months taken (e.g. daily, weekly, occasionally; months 1-9)______________
______________________________________________________________________________________________
Type of delivery (c-sectional, vaginal):
What was the child’s birth weight?
Were forceps used?
Length?
 Yes
 No
Were there any problems or complications with delivery?  Fetal Distress  Placenta Abruption  Prolapsed
Cord Unknown  Cord Around Neck  Jaundice  Unknown (Please explain)
_______________________________________________________________________________________________
Were there any problems with baby’s health before or immediately after delivery?  Yes  No  Unknown
(Please explain) ______________________________________________________________________________
Did the Child Spend any Time in the NICU after Birth  Yes  No  Unknown
If so, what was the length (in days) spent in the NICU? _______________________________________________
Were mother and baby separated after birth for more than 24 hours at a time?  Yes  No  Unknown
(Please explain)
Were there any concerns about the child’s early development/1st year?  No Concerns  Unknown
 Failure to Grow  Trouble Feeding  Respiratory Distress/Trouble Breathing  Cardiac Issues
 Other (Please Explain)
At what age did the child accomplish the following tasks?
 Roll over
 Use first words
 Crawl
 Use 2-3 word sentences
 Walk
 Build tower with cubes
 Waving bye bye/blowing kisses/pointing
 Drawing circles
 Toilet trained
 Dress themselves
Were there any accomplishments that the child mastered and then lost?  Yes  No  Unknown
(Please explain)
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2076 South Eagle Road, Meridian, Idaho 83642  Phone: (208) 955-7333  Fax: (208) 955-7330
Page 6 of 10
Does the Child have a history of sensory concerns; oversensitive to  Loud Noises  Touch  Light  Smell
 Other (Please Explain)
Has the child ever received any previous developmental therapy:  Yes  No  Unknown
Type of Therapy:  Speech/Language  Physical  Occupational Therapy  Developmental
Therapist/Agency: ________________________________________________________________________________
Length of Treatment Receive:_______________________________________________________________________
Response to Treatment:____________________________________________________________________________
Health History
Primary Care Provider:
Number of Years:
Other Provider(s):
Specialty:
Is the child currently experiencing any health problems?  Yes
 No
Date of Last Exam:
Date of Last Exam:
 Unknown (Please explain)
Is the child suffering from any allergies?  Yes  No  Unknown (Please name and describe reaction)
Health History (cont’d)
Please list the medications the child is currently taking (medical and psychiatric):
Name of Medication
Dosage/Frequency
Date Started
Please list all the psychiatric medications that have been tried in the past (if greater than 4 medications, please attach
separate list). (An medication example list can be found on the following page)
Name
Highest Dosage
Duration
Response
Reason for Stopping
Example:
Dexedrine
5mg twice daily
09/98-11/98
Good
Poor Sleep
www.nnhidaho.com
2076 South Eagle Road, Meridian, Idaho 83642  Phone: (208) 955-7333  Fax: (208) 955-7330
Page 7 of 10
Medication Examples
***Include immediate and extended
release forms***
Adderall® (dextroamphetamine +
amphetamine)
Abilify® (aripiprazole)
Adipex-P® (phentermine)
Ambien® (zolpidem)
Amitriptyline (Elavil®)
Amoxapine
Antabuse® (disulfiram)
Anafranil® (clomipramine)
Aricept® (donepezil)
Ativan® (lorazepam)
Aventyl® (nortriptyline)
Benadryl® (diphenhydramine)
Buspar® (buspirone)
Carbatrol® (carbamazepine)
Catapres® (clonidine)
Celexa® (citalopram)
Chloral hydrate
Clozaril® (clozapine)
Cogentin® (benztropine)
Concerta® (methylphenidate)
Cymbalta® (duloxetine)
Cylert® (pemoline)
Dalmane® (flurazepam)
Depakote®/Depakene® (valproic
acid/valproate
Dexedrine® (dextroamphetamine)
Didrex® (benzphetamine)
Dilantin® (phenytoin)
Dolophine®/Methadose®
(methadone)
Effexor®/Effexor XR® (venlafaxine)
Elavil® (amitriptyline)
Ephedra®
Eskalith® (lithium)
Evening primrose oil
Focalin® (dexmethylphenidate)
Gabitril® (tiagabin)
Geodon® (ziprasidone)
Ginkgo biloba
Ginseng
Halcion (triazolam)
Haldol® (haloperidol)
imipramine (Tofranil®)
Inderal® (propranolol)
Invega® (paliperidone)
Keppra® (levetiracetam)
Klonopin® (clonazepam)
Lamictal® (lamotrigine)
Lexapro® (escitalopram)
Librium® (chlordiazepoxide)
Lithobid® (lithium)
Loxitane® (loxapine)
Luminal® (phenobarbital)
Lunesta® (eszopiclone)
Luvox® (fluvoxamine)
Melatonin
Mellaril® (thioridazine)
Marplan® (isocarboxazid)
Meridia® (sibutramine)
Metadate® (methylphenidate)
Methylin® (methylphenidate)
Moban® (molindone)
Mysoline® (primidone)
Nardil® (phenelzine)
Navane® (thiothixene)
Neurontin® (gabapentin)
Norpramin® (desipramine)
Nortriptyline (Pamelor®)
Omega fatty acids
Orap® (pimozide)
Pamelor® (nortriptyline)
Parnate® (tranylcypromine)
Paxil® (paroxetine)
Periactin® (cyproheptadine)
Prolixin® (fluphenazine)
Propranolol (Inderal®)
ProSom® (estazolam)
Protriptyline (Vivactil®)
Provigil® (modafinil)
Prozac® (fluoxetine)
Remeron® (mirtazapine)
Restoril® (temazepam)
ReVia® (naltrexone)
Risperal® (risperidone)
Ritalin® (methylphenidate)
Rozerem® (ramelteon)
SAM-e
Saint John’s Wort
Sarafem® (fluoxetine)
Serax® (oxazepam)
Seroquel® (quetiapine)
Serzone® (nefazodone)
Sinequan® (doxepin)
Sonata® (zalepion)
Stelazine® (trifluoperazine) Strattera®
(atomoxetine)
Subutex® (buprenorphine)
Suboxone® (buprenorphine +
naloxone)
Symbiax® (olanzapine + fluoxetine)
Tegretol® (carbamazepine)
Tenex® (guanfacine)
Tenuate® (diethylpropion)
Thorazine® (chlorpromazine)
Tofranil® (imipramine)
Topamax® (topiramate)
Tranxene® (clorazepate)
Trazodone (Desyrel®)
Trilafon® (perphenazine)
Trileptal® (oxcarbazepine)
Valerian Root
Valium® (diazepam)
Vistaril® (hydroxyzine)
Vyvanse® (lisdexamfetamine)
Wellbutrin® (bupropion)
Xanax® (alprazolam)
Zarontin® (ethosuximide)
Zoloft® (sertraline)
Zonegran® (zonisamide)
Zyprexa® (olanzapine)
Zydis® (olanzapine)
Health History (cont’d)
Has the child ever been hospitalized for medical reasons?
 Yes
(Please explain)
 No
 Unknown
Does the child suffer from any chronic medical problems?
(Please explain)
 Yes
 No
 Unknown
Has the child had any serious illnesses, accidents, surgeries, or injuries?
(Please explain)
 Yes
 No
 Unknown
Has the child experienced any of the following health problems in the past?
 Constipation/Diarrhea
 Head injury/loss of consciousness
 Diabetes
 Seizures
 Ear/hearing problems
 Heart
 Eye/vision
 Lung
 Frequent Infections
 Thyroid Dysregulation
 Other (Please explain):
www.nnhidaho.com
 Neurological
 Tics
 Kidney/Bladder
 Weight (loss/gain)
2076 South Eagle Road, Meridian, Idaho 83642  Phone: (208) 955-7333  Fax: (208) 955-7330
Page 8 of 10
Health History (cont’d)
Has the child ever had any medical issues warranting imaging tests (MRI, EEG, CT, EKG)?  Yes  No  Unknown
Reason For Testing: _____________________________________________________________________________
Results of Testing: _______________________________________________________________________________
Please complete if your child has had any of the following Issues
Head Injuries/Concussions
How many head injuries has the child sustained?  None  One  Two  More than Two
If known, severity of head injuries?  Non-significant  Mild  Moderate  Severe
Meningitis
Age at diagnosis?
Type of Meningitis  Bacterial  Viral  Unknown
Heart Conditions
Type:  Septal Defects  Valve Defects  Other (Please Explain)____________________________
Age at diagnosis?
Have the undergone any corrective procedures?  Yes  No Age of procedure:________
Seizure Activity
If known, type of seizure  Generalized  Absence  Rolandic  Absence
Age at diagnosis?
Have the undergone any corrective procedures?  Yes  No Age of procedure:________
Genetic Abnormality  Down’s Syndrome  Chromosomal Deletion (What Chromosome: ___)  Fragile X
 Other (Please Explain) ________________________________________________________________
Are immunizations up to date?  Yes  No  Unknown
If female, age of first menstruation
(Please explain)
(Please explain)
Are cycles regular?
Have there been problems with hormonal mood dysregulation?
(Please explain)
 Yes
 No
 Unknown
 Yes
 No
 Unknown
Sleep Patterns:
Total hours of sleep per night:
Usual sleep schedule:
Does the child take naps during the day?  Yes  No If yes, how many hours per day?
Please indicate any sleep pattern concerns:
Current Problem
Difficulty falling asleep
 Yes  No
Frequent awakening
 Yes  No
Snoring
 Yes  No
Restlessness/Movements
 Yes  No
Early morning awakenings
 Yes  No
Nightmares
 Yes  No
Not rested
 Yes  No
If yes to any of the concerns, please describe:
to
Change Within Last 6 Months
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Educational Information
www.nnhidaho.com
2076 South Eagle Road, Meridian, Idaho 83642  Phone: (208) 955-7333  Fax: (208) 955-7330
Page 9 of 10
Educational Information
School
What are the child’s average grades in school?
Grade
Teacher
What are the child’s academic strengths?
What are the child’s academic challenges?
What are your child’s favorite activities?
Have there been any changes in the child’s performance at school?
(Please explain)
 Yes
 No
 Unknown
Has there been any psychoeducational (including IQ) or neuropsychological testing completed on the child at school
or elsewhere?  Yes
 No
 Unknown (Please explain and provide releases)
Does the child currently participate in special education classes or receive other special services (IEP or 504b plan)?
 Yes
 No
 Unknown (Please explain)
Have any of the child’s immediate family members had problems in school?  Yes
(Please explain)
What is the child’s attitude toward school? Positive
Has the child ever been:  Truant
 Suspended
(Please explain)
 Indifferent
 Expelled
 No
 Unknown
 Negative
 Had excessive school absences
Legal History
Has the child been involved with the police, juvenile court system, or other legal agency?  Yes  No  Unknown
(Please explain)
If applicable, please list the following:
Arrests
Detention time
Probation officer
Health and Welfare caseworker
Out of home placement (circumstances)
Signature
www.nnhidaho.com
Date
2076 South Eagle Road, Meridian, Idaho 83642  Phone: (208) 955-7333  Fax: (208) 955-7330
Page 10 of 10
Financial Policy and Agreement
Thank you for choosing Northwest Neurobehavioral Health, LLC (NNH) as your provider.
Involvement in evaluation and treatment is a partnership between you and our organization.
Upon your agreement to pay for care we agree to provide you that care. The information below
is intended to explain our billing and payment policies.
BILLING FOR OUR SERVICES

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


NNH is not responsible for contacting your insurance carrier to inquire about referrals,
benefits, and/or co-pays. It is your responsibility to check with your insurance whether
our services are covered, need to be prior authorized, and any limits to benefits. Please
bring your insurance card for us to make a copy and for claims submission.
Payment of co-payments, deductibles, and non-covered services are required at the time
service is rendered.
Clients without insurance must meet with administration to determine financial
arrangements before services will be rendered.
Northwest Neurobehavioral Health, LLC does not deny access to services based on
inability to pay. We offer sliding fee services for those who qualify.
You will receive monthly billing statements indicating the status of your account and
your current balance due.
If your account has not been paid for more than 60 days and arrangements for payment
have not been agreed upon, we have the option of using legal means to secure payment.
This may involve hiring a collection agency or going through small claims court. If such
legal action is necessary, its costs will be included in the claim.
Please call our billing company, Practice Management, Inc. at (208) 472-8112 with any
questions regarding your bill.
INSURANCE


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Your insurance policy is a contract between you and your insurance company.
Regardless of your insurance coverage, clients are ultimately responsible for payment of
their bills. Co-payments and deductible amounts are set by your insurance company and
are not subject to negotiation with Northwest Neurobehavioral Health, LLC.
You are responsible for informing the clinic about changes to your insurance coverage.
Insurance companies do not allow us to retroactively bill for services. You will be
responsible for full payment of fees if we are not informed about changes in your
insurance before services are rendered.
1
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Although we will bill on your behalf and make all reasonable efforts to obtain payment
from your insurance, if they reject the claim, or delay payment, we will look to you for
payment in full.
Submission of claims does not guarantee payment by the insurance company.
Health insurance does not relieve the client of the financial responsibility for services
rendered.
NNH is a Medicaid and Medicare provider. All Medicaid patients must provide us a
copy of the Medicaid card, Healthy Connection Referral, if applicable, and a copy of the
latest History and Physical from the primary care physician.
LATE CANCEL/NO-SHOW FEE

I understand I will be charged for appointments cancelled with less than 24 hours’ notice
and for appointments I do not attend, if applicable.
SELF PAY AGREEMENT
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I understand fees will be established based on my family income and size.
Documentation of income will be required to determine sliding fee eligibility.
I agree to inform NNH of any change in income, employment, address, telephone
number, or if I obtain insurance.
I understand if I have insurance I am not eligible for sliding fee services.
I agree to pay determined fee at the time of service.
I understand I will need to resubmit documentation for eligibility of sliding fee services
every 90 days.
INSURANCE AGREEMENT



I understand if I have an insurance deductible to meet, I will pay the full fee at the time of
service until my deductible is met. Thereafter, any insurance co-payments amount is due
at the time of service.
I understand I am responsible for providing all necessary requested insurance information
to NNH and my insurance company. If I fail to supply this information or if I choose to
not have these services submitted to my insurance company, I will be responsible for all
applicable fees at the time of service.
I assign and authorize direct payment of all benefits due for client services to Northwest
Neurobehavioral Health, LLC. A copy of this assignment may be used in lieu of the
2
original. NNH may release such information as may be necessary and pertinent to the
insurance companies named in those documents to secure payment for services.
FINANCIAL RESPONSIBILITY
I accept financial responsibility for the charges incurred by myself and/or family members
receiving services at Northwest Neurobehavioral Health, LLC. I agree to the financial terms as
outlined above.
Please initial below:
______ I understand that I am financially responsible for all evaluation and treatment costs
incurred, even if my insurance does not authorize or pay for some or all of services rendered.
______ I understand that payment is required at the time of service and upon receipt of any bill I
receive.
______ I understand if I do not make payment for services rendered the clinician I or my child
sees will not receive any payment for services they have provided.
______ I agree that if I fail to keep a scheduled appointment or do not give 24-hour notice of
cancellation I will be responsible for any no-show or late cancel charges, as applicable, which I
will pay prior to my next appointment.
______ I understand I will be charged $35 for insufficient funds.
______ I have requested and received a copy of this Financial Policy and Agreement.
___________________________________________
Client’s Signature
Date
______________________________
Printed Name of Client
___________________________________________
Parent/Legal Guardian Signature
Date
___________________________________________
NNH Representative
Date
3
COMMUNICATION CONSENT
I hereby authorize Northwest Neurobehavioral Health, LLC to leave communications for:
Patient/Client name: __________________________________________________ DOB: _____________________
Phone: ____________________ Alternate Phone: _________________________ Fax: _______________________
Email Address: __________________________________________________________________________________
I understand that at Northwest Neurobehavioral Health, LLC every effort is made to insure the confidentiality of
Protected Health Information and to comply with HIPAA Privacy and Security Standards.
Therefore, should I have information I need to discuss with the clinician regarding the status of care of my child or
of myself I will arrange a time to do this with the clinician and not have conversations where the protected health
information of my child or of myself may be compromised (i.e. in the lobby of NNH).
Furthermore, I acknowledge that from time to time NNH may need to communicate with me outside of the
appointment time. I understand that these forms of communication are not secure but consent to communication
in the following manner (s). Please initial next to each form of communication.
______
Phone messages/Voicemails
______
Email
______
Facsimile
______
Text Messaging
______
Mail
Revocation- I understand that I have a right to revoke this authorization, in writing, at any time by sending written
notification to Northwest Neurobehavioral Health, LLC at 2076 S. Eagle Rd. Meridian, Id. 83642. I further
understand that a revocation of the authorization is not effective to the extent that action has already been taken in
reliance on the authorization.
Expiration- Unless sooner revoked, this authorization expires upon termination of all services with Northwest
Neurobehavioral Health, LLC.
__________________________________________________________________________________________
Signature of Patient/Client (If 14+ Years of Age)
Date
__________________________________________________________________________________________
Signature of Parent, Guardian or Personal Representative
Date
(If you are signing as a personal representative of an individual, please describe your authority to act for this
individual, for example; power of attorney, healthcare surrogate, etc.)
www.nnhidaho.com
2076 South Eagle Road, Meridian, Idaho 83642
Phone: (208) 955-7333 Fax: (208) 955-7330
Information for Clients/Consent to Treatment
Welcome to our practice. We appreciate your giving us the opportunity to be of help to you. This form will help
answers some questions clients often ask about any therapy practice. It is important to us that you know how we will
work together. Please read this carefully and write down any questions you might have so that we can discuss them
at our next meeting.
Testing
This assessment will involve evaluation of intellectual, academic, personality and/or emotional functioning. It will
not involve any psychotherapy, medical procedures or medical treatment. Providing information about your
background, family and/or child will be included in a clinical interview. Please speak with the testing therapist
regarding specific instruments that will be used and tasks that will be required.
The information generated from the clinical interview and the testing results will be used to formulate a written
report. When the report has been completed, a feedback session will be scheduled in order to share the results with
the guardian, and child, if appropriate. At the feedback session, information about test performance, areas of
strengths and weaknesses, diagnoses, possible modes of treatment and recommendations may be provided.
Our current fees range from $1450 to $2250 for a full battery; a full battery varies depending on the nature of the
presenting problem and requested information. If you have questions, please speak with the testing therapist
regarding your specific battery. Relatively brief testing evaluation will be billed per hour, with hourly rates ranging
from $145 to $225. The fees include the time spent with the client, feedback session as well as time needed to score
and write the evaluation. Our services may be partly reimbursable under your health plan. In most cases, we will
bill directly for services rendered. The insurance company will send the payment directly to us, but you will be
responsible for any co-insurance payment, deductible and any services deemed uncovered by the insurance
company. Therefore, if for any reason, your insurance company fails to pay the full amount expected, the
responsible party will be required to pay the balance. Payment is expected at the time of your first appointment.
Please speak with an office staff member regarding the types of insurance we accept. We require at least 24 hours’
notice for a cancellation. If the appointment is cancelled with less than 24 hours, this will be considered a late
cancel. You will be charged a $20 fee for Late Cancels and No-Shows. After receiving 2 late cancels or noshows your child’s therapy will be suspended.
Occupational Therapy
Occupational Therapy Services are provided within the scope of practice of licensed occupational
therapists. These services are necessary for the evaluation and treatment of impairments, functional
disabilities, or changes in physical function and health status; and the goal to improve the individual’s
ability to perform those tasks required for independent functioning. Occupational Therapy may involve
removal of some clothing articles, palpation (manual examination) of body part(s) and close observation
of body part(s). I consent to the use of photographs for postural comparison and educational purposes
during evaluation and reevaluation.
The treatment will be discussed prior to its application and that at any time you have the right to refuse
treatment. No assurance or guarantee has been provided to me as to the results of the treatment. With any
treatment there can be risks.
At NNH our Occupational Therapist must be fully aware of your child’s existing medical conditions. You
must have completed the medical history form and have disclosed all of the medical conditions affecting
you.
We require at least 24 hours’ notice for a cancellation. If the appointment is cancelled with less than 24 hours, this
will be considered a late cancel. You will be charged a $20 fee for Late Cancels and No-Shows. After
receiving 2 late cancels or no-shows your child’s therapy will be suspended.
Speech Therapy
Speech Therapy Services are provided within the scope of practice of licensed speech-language
pathologists. Speech-language pathology services are necessary for the evaluation and treatment of
speech and language disorders which may result in communication disabilities; or necessary for the
evaluation and treatment of swallowing disorders (dysphagia), regardless of the presence of
communication disability. A plan of treatment, including goals of treatment, is developed by the patient
and the speech therapist together after an initial evaluation of the problem is performed. This plan is sent
to the referring physician for approval. The patient acknowledges that no guarantee has been given as to
the outcome of this speech therapy plan of care. The patient agrees to notify NNH if he/she has previously
seen another speech therapist for treatment of this condition or if he/she sees another such therapist
during treatment with NNH.
We require at least 24 hours’ notice for a cancellation. If the appointment is cancelled with less than 24 hours, this
will be considered a late cancel. You will be charged a $20 fee for Late Cancels and No-Shows. After
receiving 2 late cancels or no-shows your child’s therapy will be suspended.
Physician Services
NNH provides medication evaluation and management with our team of Psychiatrists, Physicians, and Board
Certified Psychiatric Nurse Practitioners. Prescription refills may be requested with one-week notice. Refills can be
requested by having the pharmacy fax your request to NNH. The fax number is (208) 955-7330; or schedule an
appointment to see a physician to have the refill authorized. Physician’s fees are hourly ranging from $65 to $400.
You will be expected to pay for each session at the time of service. We require at least 24 hours’ notice for a
cancellation. If the appointment is cancelled with less than 24 hours, this will be considered a late cancel. You will
be charged a $20 fee for Late Cancels and No-Shows. After receiving 2 late cancels or no-shows your child’s
medication management will be suspended.
Psychotherapy
Because you will be putting a good deal of time, money, and energy into therapy, you should choose a therapist
carefully. You have the right to ask us about other treatments for your condition and potential risks and benefits. If
at any time, you wish another professional’s opinion and wish to consult with another therapist, we will assist you in
finding someone qualified and provide him or her with the essential information needed.
Psychotherapy is not like visiting a medical doctor in that it requires your very active involvement and efforts to
change your thoughts, feelings, and behaviors. It will be important for you to offer your feelings about treatment
and progress you are making. Offering your views and responses when they are important to you is one of the ways
you are an active partner in this process. You will have work to do both in the therapy office and many other times
not spent in the therapeutic situation. There may be “homework”: assignments and will certainly be time spent
working on your personal relationships. Change will sometimes be easy and swift, but more often it will be slow,
frustrating, and require a need for repetition.
As with any powerful treatment, there are both benefits and risks associated with psychotherapy. Risks might
include experiencing uncomfortable levels of feeling like sadness, guilt, anxiety, anger, frustration, loneliness, and
helplessness. You may begin recalling unpleasant aspect of your history or experience difficulties with close
relatives or friends. Some changes may lead to losses, such as deciding to end a relationship or change careers.
Despite the above-mentioned risks, you should know that psychotherapy has been repeatedly scientifically
demonstrated to be of benefit for most people and most situations. Benefits might include the lifting of depression,
diminished anxiety or anger, improvements in relationships and skills.
We require at least 24 hours’ notice for a cancellation. If the appointment is cancelled with less than 24 hours, this
will be considered a late cancel. You will be charged a $20 fee for Late Cancels and No-Shows. After
receiving 2 late cancels or no-shows your child’s therapy will be suspended.
Psychotherapy with a Minor
You as the parent/guardian have a right to know about the treatment process. We agree that therapists may talk with
parents/guardians to discuss how your child is doing with general information. The things talked about in meetings
with the therapist are private. Therapist will not tell others about the specific things told to him or her. He or she
will not repeat these things to parents/guardians, teachers, the police, probation officers, or clinic employees. But
there are two exceptions. First, because of the law, the therapist will tell others what has been said if the minor talks
about hurting them self or someone else. Therapist will have to tell someone who can help protect the minor or the
person the minor talked about hurting. Second, if the minor is being seriously hurt by anyone, this therapist has to
inform Child Protection Services and/or local police for the minor’s protection.
Parents/guardians have the right to ask about other treatments for the child’s condition and potential risks and
benefits. If at any time, you wish to receive another professional’s opinion or wish to consult with another therapist
we will assist in finding someone qualified and provide him or her with the essential information needed.
When difficult issues arise in therapy, children sometimes feel angry, sad or guilty. If any of these things become
evident, please mention them to the therapist. Please encourage the child to directly discuss them with the therapist
and ask any questions they may have about treatment.
Psychotherapy can have benefits and risks. Therapy often involves discussing unpleasant aspects of your child’s life.
Your child may experience uncomfortable feelings like sadness, guilt, anger, loneliness and helplessness.
Psychotherapy has been shown to have benefits for those who commit to therapy.
Our first sessions will involve an evaluation of your child’s needs and situation. After the evaluation the therapist
will be able to offer you his/her clinical impression. You and your child will be involved in the treatment planning
process. Therapy involves a large commitment of time, money and effort. If at any time you have doubts about the
therapy provided we will assist you the referral sources.
_______
INITIAL
I UNDERSTAND THAT MY THERAPIST, PHYSICIAN, OR NURSE
PRACTITIONER WILL NOT BE INVOLVED IN COURT-ORIENTED
ACTIVITIES, INCLUDING TESTIFYING IN CUSTODY MATTERS. IT IS
THE POLICY OF NORTHWEST NEUROBEHAVIORAL HEALTH TO
SUPPORT THE CLIENT THERAPEUTICALLY AND NOT TO ENTER
INTO LEGAL PROCEEDINGS. NORTHWEST NEUROBEHAVIORAL
HEALTH DOES NOT OFFER ANY CUSTODY EVALUATIONS OR HOME
STUDY SERVICES. CLINICIANS, IN THEIR ROLE AS NORTHWEST
NEUROBEHAVIORAL
HEALTH
THERAPISTS
OR
MEDICAL
PROVIDERS,
DO
NOT
GIVE
LEGAL
OPINIONS
OR
RECOMMENDATIONS REGARDING CUSTODY OR CUSTODIAL
ISSUES. IN THE UNLIKELY EVENT THAT A THERAPIST, PHYSICIAN
OR NURSE PRACTITIONER IS SUBPOENAED AS A WITNESS BY A
JUDGE, FEES FOR THE REQUESTING PARTY WILL BE BILLED AT
$200 PER HOUR FOR A THERAPIST AND $400 PER HOUR FOR A
PHYSICIAN OR NURSE PRACTITIONER, WITH A MINIMUM FOURHOUR CHARGE. SUCH FEES ARE NOT BILLABLE TO INSURANCE
AND ARE DUE A MINIMUM OF ONE WEEK BEFORE THE
SCHEDULED COURT APPEARANCE. FEES ARE NOT REFUNDABLE,
DESPITE ANY CANCELLATION MADE WITHIN 24 HOURS.
Appointments
Psychotherapy appointments are usually scheduled as one 50-minute session one time per week. Once an
appointment is scheduled for you or your child you will be expected to pay for that session at the time of the
scheduled session. Our hourly fees for psychotherapy range from $90 to $200. You will be expected to pay for each
session at the time of service. We require at least 24 hours’ notice for a cancellation. If the appointment is
cancelled with less than 24 hours, this will be considered a late cancel. You will be charged a $20 fee for Late
Cancels or No-Shows. After receiving 2 late cancels or no-shows your child’s therapy will be suspended.
Professional Fees/Billing Payments
Insurance carriers will be billed as a courtesy to you. If your policy requires a referral form and/or co-pay you will
be solely responsible to have these items the day of your appointment. Additionally, if you have not met the yearly
deductible for your insurance you will be required to pay toward that deductible at the time of each appointment
until the deductible amount is met. NNH is not responsible for calling your insurance carrier to inquire about
referrals, benefits, and/or co-pays. Please bring your insurance card for us to make a copy. This will assist us in
submitting your claims. If your insurance company has not paid NNH in a timely manner, you will be responsible
for payment of all charges incurred.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon,
we have the option of using legal means to secure payment. This may involve hiring a collection agency or going
through small claims court. If such legal action is necessary, its costs will be included in the claim.
NNH is a Medicaid and Medicare provider. All Medicaid patients must provide us a copy of the Medicaid card,
Healthy Connection Referral, and a copy of the latest History and Physical.
Northwest Neurobehavioral Health, LLC does not deny access to services based on inability to pay. We offer
sliding fee services for those who qualify.
Professional Records
The laws and standards of the mental health profession require the NNH keep treatment records. Clients are entitled
to receive a copy of these records or NNH can provide a summary (verbally or written). Clients may be charged a
small fee for this service.
Confidentiality
In general, the law protects the privacy of all communication between a client and a clinician, and NNH can release
information about our work to others only with your written consent. There are a few exceptions:
-If a clinician at NNH believes that a client is threatening serious bodily harm to another.
-If there is reason to believe client may hurt him/herself or someone else.
-If there is reason to believe the client may be abused or neglected.
-If there are legal proceedings to settle this account.
-If the records are subpoenaed by the court.
The above described are the situations in which NNH records would be released. We will not release any
information about you or your treatment, diagnosis, or client identification, without the full knowledge and signed
release of information form.
Please review and sign the Notice of Privacy Practices for additional information regarding information related to
the protection of you or your child’s medical information.
Safety
Northwest Neurobehavioral Health, LLC strictly prohibits the presence of the following items on premise:
-Firearms
-Alcohol and/or illicit drugs
If someone has these items they will be asked to leave and Emergency Personnel may be contacted.
Please keep your children, including non-clients, within your eyesight at all times. Do not allow your child to leave
the premises without you.
In the event of a fire or other emergency please proceed to the nearest exit and gather at the location indicated on the
Fire map. Please listen to staff for additional direction. If your child is being seen at the time of the emergency their
clinician will meet you, with your child, at the location indicated above.
Health
In an effort to minimize the risk of the spread of infectious diseases between clients and NNH staff we require
cancellation of appointments in the case of infectious illness. Staff members will notify supervisor and Director of
Operations of exposure to, or known infection with, general communicable diseases (which include, but are not
limited to, influenza, meningitis, mumps, whooping cough, measles, diphtheria, lice, chicken pox, and tuberculosis),
and to see a medical provider to develop a plan which minimizes the risk to others becoming infected.
Employees and/or clients shall be temporarily restricted from the clinic if infected with communicable respiratory
illness or contagious illness. They will be allowed back in the clinic after they have been cleared by a physician or
have gone 24 hours without symptoms of any kind (fever, vomiting, rash, etc.). When necessary, the Director of
Operations will communicate with the public health officials regarding infectious disease exposure. The Idaho
Reportable Disease List will be utilized for further information. You and/or your child are welcome to return to the
clinic when you have been asymptomatic for a 24 hour period.
Consent
Your signature below signifies that you have been informed and understand the services to be received; expected
benefits and potential risks of receiving those services; your right to refuse services; and that you will be provided
with alternative forms of services available through referral resources, if requested. Furthermore, your signature
indicates that you agree to abide by the terms of this document.
____________________________________________
Client’s Signature
____________________________________
Parent/Guardian Signature
____________________________________
Date
_____________________________
Relationship
____________________________________________
Clinician’s Signature
______________
Date
____________________________________
Date
2076 S. Eagle Rd. Meridian, ID 83642 Phone: (208)955-7333 Fax: (208)955-7330
NOTICE OF PRIVACY PRACTICES
This notice is effective February 18, 2010
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
WE ARE REQUIRED BY LAW TO PROTECT MEDICAL INFORMATION ABOUT YOU
We are required by law to protect the privacy of medical information about you and information that identifies you.
This medical information may be information about health care we provide to you or payment for health care
provided to you. It may also be information about your past, present, or future medical condition(s).
We are also required by law to provide you with this Notice of Privacy Practices ex plaining our legal duties and
privacy practices with respect to medical information. We are legally required to follow the terms of this Notice. In
other words, we are only allowed to use and disclose medical information in the manner that we have described in
this Notice.
We may change the terms of this Notice in the future. We reserve the right to make changes and to make the new
Notice effective for all medical information that we maintain. If we make changes to the Notice we will:
•
•
Post the new Notice in our waiting area
Have copies of the new Notice available upon request (you may always contact our Privacy Officer at 208955-7333 to obtain a copy of the current Notice)
The rest of this Notice will:
•
•
•
Discuss how we may use and disclose medical information about you
Ex plain your rights with respect to medical information about you
Describe how and where you may file a privacy-related complaint
If at any time you have questions about information in this Notice or about our privacy policies, procedures, or
practices, you can contact our Privacy Officer at 208-955-7333.
WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU IN
SEVERAL CIRCUMSTANCES
We use and disclose medical information about patients every day. This section of our Notice explains how we may
use and disclose medical information about you in order to provide health care, obtain payment for that health care,
and operate our business efficiently. This section then briefly mentions several other circumstances in which we may
use or dis close medical information about you. For more information about any of these uses or dis closures or about
any of our privacy policies, procedures, or practices contact our Privacy Officer at 208-955-7333.
1. Treatment
We may use and disclose medical information about you to provide health care treatment to you. In other
words, we may use and disclose medical information about you to provide, coordinate, or manage your health
care and related services. This may include communicating with other health care providers regarding your
treatment and coordinating and managing your health care with others.
www.nnhidaho.com
2076 South Eagle Road, Meridian, Idaho 83642 • Phone:(208) 955-7333 • Fax:(208) 955-7330
Page 16 of 21
2. Payment
We may use and disclose medical information about you to obtain payment for health care services that you
received. This means that, within the health department, we may use medical information about you to arrange
for payment (such as insurers, collection agencies, and consumer reporting agencies). In some instances, we
may disclose medical information about you to an insurance plan before you receive certain health care
services because, for example, we may want to know whether the insurance plan will pay for a particular service.
3. Healthcare Operations
We may use and disclose medical information about you in performing a variety of business activities that we call
"health care operations." These "health care operations" activities allow us to improve the quality of care we
provide and reduce health care costs. For example, we may use or disclose medical information about you in
performing the following activities:
•

•

•
•
•
•
•
•
Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care
of you
Providing training programs for students, trainees, health care providers, or non-health care
professionals to help them practice or improve their skills
Cooperating with outside organizations that evaluate, certify, or license health care providers, staff and
or facilities in a particular field or specialty
Reviewing and improving the quality, efficiency, and cost of care that we provide to you and our other
patients
Improving health care and lowering costs for groups of people who have similar health problems and
helping manage and coordinate the care for these groups of people
Cooperating with outside organizations that assess the quality of the care others and we provide,
Including, government agencies and private organizations
Planning for our organization's future operations
Resolving grievances within our organization
Reviewing our activities and using or disclosing medical information in the event that control of our
organization significantly changes
Working with others (such as lawyers, accountants, and other providers) who assist us to comply with
this Notice and other applicable laws
4. Persons Involved in Your Care
We may disclose medical information about you to a relative, close personal friend, or any other person you
identify if that person is involved in your care and the information is relevant to your care. If the patient is a
minor, we may disclose medical information about the minor to a parent, guardian, or other person responsible
for the minor except in limited circumstances. For more information on the privacy of minors' information,
contact our Privacy Officer at NNH 208-955-7333.
We may also use or disclose medical information about you to a relative, another person involved in your care, or
possibly a disaster relief organization (such as the Red Cross) if we need to notify someone about your location or
condition.
You may ask us at any time not to disclose medical information about you to persons involved in your care. We
will agree to your request and not disclose the information except in certain limited circumstances (such as
emergencies) or if the patient is a minor. If the patient is a minor, we may or may not be able to agree to your
request.
5. Required by Law
We will use and disclose medical information about you whenever we are required to by law to do so. There are
many state and federal laws that require us to use and disclose medical information. For example, state law
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Requires us to report known or suspected child abuse or neglect to the Department of Social Services
and/or police. We will comply with those state laws and all other applicable laws.
6. National Priority Uses and Disclosures
When permitted by law, we may use or disclose medical information about you without your permission for
various activities that are recognized as "national priorities " In other words, the government has determined
that under certain circumstances (described below), it is so important to disclose medical information that it is
acceptable to disclose medical information without the individual's permission. We will only disclose medical
information about you in the following circumstances when we are permitted to do so by law. Below are brief
descriptions of the "national priority" activities recognized by law. For more information on these types of
disclosures, contact our Privacy Officer at NNH 208-955-7333.
•
•
•
•
•
•
•
Threat to health or safety: We may use or disclose medical information about you if we believe it is
necessary to prevent or lessen a serious threat to health or safety.
Public health activities: We may use or disclose medical information about you for public health
activities. Public health activities require the use of medical information for various activities, including,
but not limited to, activities related to investigating diseases, reporting child abuse and neglect,
monitoring drugs or devices regulated by the Food and Drug Administration, and monitoring work-related
illnesses or injuries. For example, if you have been exposed to a communicable disease, (such as a
sexually transmitted disease), we may report it to the State and take other actions to prevent the spread
of the disease.
Abuse, neglect, or domestic violence: We may disclose medical information about you to a government
authority, (such as the Department of Social Services), if you are an adult and we reasonably believe
that you may be a victim of abuse, neglect, or domestic violence.
Health oversight activities: We may disclose medical information about you to a health oversight agency
- which is basically an agency responsible for overseeing the health care system or certain government
programs. For example, a government agency may request information from us while they are
investigating possible insurance fraud.
Court proceedings: We may disclose medical information about you to a court or an officer of the court
(such as an attorney). For example, we would disclose medical information about you to a court if a
judge orders us to do so.
Law enforcement: We may disclose medical information about you to a law enforcement official for
specific law enforcement purposes. For example, we may disclose limited medical information about you
to a police officer if the officer needs the information to help find or identify a missing person.
Coroners and others: We may disclose medical information about you to a coroner, medical examiner,
funeral director, or to organizations that help with organ, eye, and tissue transplants.
Workers' compensation: We may disclose medical information about you in order to comply with
workers' compensation laws.
Research Organizations: We may use or disclose medical information about you to research
organizations if the organization has satisfied certain conditions about protecting the privacy of medical
information.
Certain government functions: We may use or disclose medical information about you for certain
government functions, including but not limited to military and veterans' activities and national security
and intelligence activities . We may also use or disclose medical information about you to a correctional
institution in some circumstances.
7. Authorizations
Other than the uses and disclosures described above (# 1- 6), we will not use or disclose medical information
about you without the "authorization" - or signed permission- of you or your personal representative. In some
instances, we may wish to use or disclose medical information about you and we may contact you to ask you to
sign an authorization form. In other instances, you may contact us to ask us to disclose medical information, and
we will ask you to sign an authorization form.
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If you sign a written authorization allowing us to disclose medical information about you, you may later revoke
(or cancel) your authorization in writing, (except in very limited circumstances related to obtaining insurance
coverage). If you would like to revoke your authorization, you may write us a letter revoking your authorization
or fill out an Authorization Revocation Form. Authorization Revocation Forms are available from our Privacy
Officer. If you revoke your authorization, we will follow your instructions except to the extent that we have
already relied upon your authorization and taken some action.
YOU HAVE RIGHTS WITH RESPECT TO MEDICAL INFORMATION ABOUT
YOU
You have several rights with respect to medical information about you. This section of the Notice will briefly mention
each of these rights. If you would like to know more about your rights, please contact our Privacy Officer at NNH
208-955-7333.
1. Right to a Copy of This Notice
You have a right to have a paper copy of our Notice of Privacy Practices at any time. In addition, a copy of this
Notice will always be posted in our waiting area. If you would like to have a copy of our Notice, ask the
receptionist for a copy or contact our Privacy Officer at NNH 208-955-7333.
2. Right of Access to Inspect and Copy
You have the right to inspect (which means see or review) and receive a copy of medical information about you
that we maintain in certain groups of records. If we maintain your medical records in an Electronic Health Record
(EHR) system, you may obtain an electronic copy of your medical records. You may also instruct us in writing to
send an electronic copy of your medical records to a third party. If you would like to inspect or receive a copy of
medical information about you, you must provide us with a request in writing. You may write us a letter
requesting access or fill out an Access Request Form. Access Request Forms are available from our Privacy
Officer.
We may deny your request in certain circumstances. If we deny your request, we will explain our reason for
doing so in writing. We will also inform you in writing if you have the right to have our decision reviewed by
another person.
If you would like a copy of the medical information about you, we will charge you a fee to cover the costs of
the copy. Our fees for electronic copies of your medical records will be limited to the direct labor costs
associated with fulfilling your request.
We may be able to provide you with a summary or explanation of information. Contact our Privacy Officer for
more information on these services and any possible additional fees.
3. Right to Have Medical Information Amended
You have the right to have us amend (which means correct or supplement) medical information about you that
we maintain in certain groups of records. If you believe that we have information that is either inaccurate or
incomplete, we may amend the information to indicate the problem and notify others who have copies of the
inaccurate or incomplete information. If you would like us to amend information, you must provide us with a
request in writing and explain why you would like us to amend the information. You may either write us a letter
requesting an amendment or fill out an Amendment Request Form. Amendment Request Forms are available
from our Privacy Officer .
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We may deny your request in certain circumstances. If we deny your request, we will explain our reason for
doing so in writing. You will have the opportunity to send us a statement explaining why you disagree with our
decision to deny your amendment request, and we will share your statement whenever we disclose the
information in the future.
4. Right to an Accounting of Disclosures We Have Made
You have the right to receive an accounting (which means a detailed listing) of disclosures that have been made
for the previous six (6) years. If you would like to receive an accounting, you may send us a letter requesting an
accounting, fill out an Accounting Request Form, or contact our Privacy Officer. Accounting Request Forms are
available from our Privacy Officer.
The accounting will not include several types of disclosures, including disclosures for treatment, payment, or
health care operations. If we maintain your medical records in an Electronic Health Record (EHR) system, you
may request that include disclosures for treatment, payment, or health care operations. The accounting will not
include disclosures made prior to Aprill4, 2003.
If you request an accounting more than once very twelve (12) months, we may charge you a fee to cover the
costs of preparing the accounting.
5. Right to Request Restrictions on Uses and Disclosures
You have the right to request that we limit the use and disclosure of medical information about you for
treatment, payment, and health care operations. Under federal law, we must agree to your request and comply
with your requested restriction(s) if:
•
•
Except as otherwise required by law, the disclosure is to a health plan for purpose of carrying out
payment of health care operations (and is not for purposes of carrying out treatment); and
The medical information pertains solely to a health care item or service for which the health care
provided involved has been paid out-of-pocket in full.
Once we agree to your request, we must follow your restrictions (except if the information is necessary for
emergency treatment). You may cancel the restrictions at any time. In addition, we may cancel a restriction at
any time as long as we notify you of the cancellation and continue to apply the restriction to information
collected before the cancellation.
6. Right to Request an Alternative Method of Contact
You have the right to request to be contacted at a different location or by a different method. For example, you
may prefer to have all written information mailed to your work address rather than to your home address.
We will agree to any reasonable request for alternative methods of contact. If you would like to request an
alternative method of contact, you must provide us with a request in writing. You may write us a letter or fill out
an Alternative Contact Request Form. Alternative Contact Request Forms are available from our Privacy Officer.
.
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YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES
If you believe that your privacy rights have been violated, or if you are dissatisfied with our privacy policies or
procedures, you may file a written complaint either with us or with the federal government.
We will not take any action against you or change our treatment of you in any way if you file a complaint.
To file a written complaint with us, you may bring your complaint directly to our Privacy Officer, or you may mail it to
the following address:
Northwest Neurobehavioral Health, LLC
2076 S. Eagle Road
Meridian, ID 83642
(208) 955-7333
To file a written complaint with the federal government, please use the following contact information:
U.S. Department of Health and Human
Services Office for Civil Rights
200 Independence Ave. S.W.
Room 509F,HHH Building
Washington, D.C. 20201
Toll-Free Phone : (800) 368-1019
TDD Toll-Free: (800) 537-7697
Website: http://www .hhs.gov I ocr/privacy/h ipaa/ com pia ints/index .htmI
Email: OCRMail@hhs.gov
Your signature below agrees that you have read this information and agree to abide by its’ terms.
Client's Signature
Parent/Guardian Signature
Therapist's Signature
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Date
Relationship
Date
Date
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Audio and Video Consent
I understand that some sessions or portions of sessions may be videotaped or recorded and
that the resulting tapes or recordings may be used for general training proposes including but
not limited to: General clinic training, use in this client’s treatment, evaluation and supervision
of interns or other staff in educational programs associated with Northwest Neurobehavioral
Health, LLC and quality assurance and quality improvement of clinic processes. All such tapes
and recordings may be destroyed as determined by NNH.
_____________________________________
Client’s Name
___________________________________
Date
_____________________________________
Parent/Guardian Signature
___________________________________
Date
_____________________________________
Clinician’s Signature
___________________________________
Date
ALERT
®
Wellness Assessment - Youth
Completing this brief questionnaire will help us provide services that meet your child's needs. Answer each
question as best you can and then review your responses with your child's clinician. Shade circles like this
Child's Last Name
Child's Date of Birth: (mm/dd/yy)
First Name
,
/
Subscriber ID
/
Authorization #
Clinician Last Name
First Name
Today's Date: (mm/dd/yy)
,
Clinician ID/Tax ID
/
/
State
Clinician Phone
Visit #:
MRef
1 or 2
3 to 5
Other
Relationship to child: Mother
Father
Stepparent
Other Relative
Child/Self
For questions 1-21, please think about your experience in the past week.
Never
Sometimes
Fill in the circle that best describes your child:
1. Destroyed property
2. Was unhappy or sad
3. Behavior caused school problems
4. Had temper outbursts
5. Worrying prevented him/her from doing things
6. Felt worthless or inferior
7. Had trouble sleeping
8. Changed moods quickly
9. Used alcohol
10. Was restless, trouble staying seated
11. Engaged in repetitious behavior
12. Used drugs
13. Worried about most everything
14. Needed constant attention
How much have your child's problems caused:
15.
16.
17.
18.
19.
20.
21.
Not at All
A Little
Other
Often
Somewhat
Interruption of personal time?
Disruption of family routines?
Any family member to suffer mental or physical problems?
Less attention paid to any family member?
Disruption or upset of relationships within the family?
Disruption or upset of your family's social activities?
How many days in the past week was your child's usual routine interrupted by their problems?
A Lot
Days
Answer the following only if this is your first time completing this questionnaire for this child.
Excellent
Very Good
Good
Fair
Poor
22. In general, would you say your child's health is:
2-3
4-5
6+
23. In the past 6 months, how many times did your child visit a medical doctor? None 1
24. In past month, how many days were you unable to work because of your child's problems?
Days
(answer only if employed)
25. In the past month, how many days were you able to work but had to cut back on
how much you got done because of your child's problems?
(answer only if employed)
Days
59243
Clinician: Please fax to (800) 985-6894
Rev. 2007