www.reddoorpediatric.comBismarck Location Minot Location2625 N 19th Street 601 18th Ave SE Suite 201Bismarck, North Dakota 58503 Minot, ND 58701

Phone: 701-222-3175Fax: 701-222-3186

Our evaluation of your child will depend on information about his/her past history. Fill out this form as completely as possible and bring with you the day of the evaluation. If you have questions regarding any items, put a checkmark in the left margin and we can discuss them when you come for your appointment. Today’s date:Person completing form (first/last name):Relationship to child:

If you are not the child’s current legal guardian, please list the legal guardian:

IDENTIFICATION:Child’s full name:

Birthdate:

Sex:

Age:

Who does the child live with?

Address of child’s primary residence:

City:

State:

Zip:

Mother Father

Name: Name:

Age: DOB: Age: DOB:

Cell phone #: Cell phone #

Home phone # (if different than cell phone #s):

Place of Employment: Place of Employment:

Occupation: Occupation:

Work phone #: Work phone #:

Email: Email:

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Preferred method of contact (phone call or email):

Emergency contact (name and phone number):

Relationship to child:

Siblings:

Name Age Sex Grade Speech/language, OT, medical conditions:

PHYSICIAN INFORMATION:Child’s Primary Doctor:___________________________________________________________________

PREGNANCY/BIRTH HISTORY:Which pregnancy was this child?

Were there any illness, diseases, or accidents that occurred during pregnancy?

Was there in utero exposure to drugs or alcohol?

Age of mother at child’s birth:

Age of father at child’s birth:

Length of pregnancy: Type of delivery:

Birth weight: Apgar scores:

Length of labor: Was labor difficult?

Was medical intervention needed during labor/delivery (if yes, please explain (ex. induction, forceps, epidural,

blood transfusion, etc.)?

Were there any bruises, scars, or abnormalities to the child’s head?

Did the child require oxygen? yes / no Was child “blue”? yes / no Was the child jaundice? yes / no

Were there any problems immediately following birth or during the first two weeks of the child’s life (ex. NICU,

nursing, swallowing, sucking, feeding, sleeping, etc.)? If so, describe:

DEVELOPMENTAL HISTORY: At what age did the child develop the following skills:

Rolled over alone: Sat alone: Crawled:

Stood alone: Walked unaided: Fed self with spoon:

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Bladder trained: Bowel trained: Consumed solid foods:

First word: First phrase: Conversation:

Do you have: YES NO

Communication concerns

Fine motor concerns

Gross motor concerns

Sensory concerns

Please describe the child’s overall social behavior?

The child prefers to: Play alone_______ Parallel play_______ Play with others________(*parallel play is to play alongside other children, but not with other children)

MEDICAL HISTORY:Is the child now under the care of a doctor?

Why?

Does the child currently carry any medical diagnoses?

If yes, please indicate diagnoses, medical professional who made the diagnoses, and date of diagnoses:

Is he/she taking medication? Type?

Is he/she taking supplements? Type?

Are the child’s immunizations current?

At what age did any of the following occur? Indicate severity.

Age Mild Mod Severe Age Mild Mod Severe

Adenoidectomy Influenza

Chronic colds PE tubes

Cross-eyed Pneumonia

Croup Strep throat

Earaches/ear infections

Seizures

Headaches Tonsillectomy

Heart murmur Whooping cough

Other:

Known allergies:

Has the child ever had an extremely long, high fever? If yes, please explain:

Has the child ever fallen or had a blow to the head? If so, did he/she lose consciousness?

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Did it cause a concussion?

Did it cause nausea?

Vomiting?

Did any of the above require hospitalization?

Surgical history:

Is the child currently seen by a Chiropractor?

When was the last time the child has been to the dentist?Any concerns reported?If yes, explain:When was the last time the child has been to the eye doctor?Any concerns reported?If yes, explain:Does your child currently wear glasses?When was the last time the child has had his/her hearing checked?Any concerns reported?If yes, explain:

BEHAVIOR:Check these as they apply to your child.

Yes No Explain:

Eating problems

Sleeping problems

Toilet training problems

Difficulty concentrating

Difficulty staying with an activity

Requires a lot of discipline

Underactive

Overactive

Cries a lot

Sensitive/Emotional

Likes rough play

Irritable

Difficulty getting along with children

Difficulty getting along with adults

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Difficulty making friends

Has frequent tantrums

Frequently fearful

Gets stuck on topics

Obsessions/compulsions

Avoids eye contact

Has limited interests

Confused by gestures

Misinterprets social situations

Does the child separate from his/her caregivers without crying or fussing?

Are you concerned with your child’s behavior? If so, what is most concerning to you?

How do you deal with negative behaviors or what discipline method works best?

Favorite play or motivating activities for your child?

EDUCATIONAL HISTORY:Does the child attend daycare? Where? How many hours per week?

Does the child attend school? Where? Grade?

What are his/her average grades: Best subjects: Challenging subjects:

Is the child frequently absent from school?

If so, why?

How does the child feel about school or his/her teacher?

Has anyone ever thought he/she has learning difficulties (ex., dyslexia)?

Describe any speech, language, hearing, occupational/physical therapy, psychological, or special education

services that your child is currently enrolled in. How often does your child attend this service?

ADDITIONAL INFORMATION:What are your primary concerns and reasons for seeking an evaluation:

Please add any additional information you want us to know :

How did you hear about Red Door?

DIAPER AND TOILETING PROCEDURES:When necessary, Red Door Pediatric Therapy staff may change a child’s diaper and/or provide toileting assistance under the following conditions:-consent has been signed (see below)-it is understood that no application of creams, powders, or ointments will be administered

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-it is understood that parents/caregivers are responsible for providing diapers, wipes, and a change of clothes in the event of an accident

Consent for Diaper Changing:

I, _____________________________, give permission for Red Door Pediatric Therapy staff to change (print parent/guardian name)

_______________________________’s diaper and/or assist with toileting as necessary. I understand and agree (print child’s name)to the terms listed above. I also understand that I may revoke this permission at any time.

Parent/guardian’s signature:_____________________________________________

Date: ____________________

CONFIDENTIALITYAs mandated by law, we are required to report any suspected child molestation, neglect and emotional or physical abuse to protect the children involved.

_________Initials __________Date

Signature of person filling out form:____________________________________Date:__________________

See insurance information on the following page

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Insurance Information

Primary coverage:

Child name:

Policyholder:

Policy ID number:

Group number:

Insurance provider number:

Insurance Company Name:Address:Phone Number:

Secondary coverage if applicable:

Child name:

Policyholder:

Policy ID number:

Group number:

Insurance provider number:

Insurance Company Name:Address:Phone Number:

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I hereby acknowledge that the information provided above is accurate and current:

Signature___________________________________ Date:____________

Notice of Policies and Practices to Protect the Privacy of Your Health Information

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

Introduction: This notice describes how Red Door Pediatric Therapy handles information about your—how information is used in the office, how information might be shared with other professionals and organizations, and how that information can have accessed. It is important to understand these policies so that the best decisions for you and your family can be made about personal and medical health information. It is a requirement to provide this information to you as a result of privacy regulations of a federal law and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Each time there is a visit by any healthcare provider, information is collected about your physical and mental health. The information is called, according to HIPAA, Protected Health Information (PHI). This information goes into a healthcare record within our office. This information is likely to include the following:

● Past history: childhood, school, work and marital history ● Reason for seeking treatment ● Diagnosis/diagnoses ● Progress notes ● Records from other practitioners treating your child● Legal matters ● Insurance and billing information

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

● “PHI” refers to information in your health record that could identify you. ● “Treatment, Payment and Health Care Operations” (TPO)

○ Treatment is when we provide, coordinate or manage health care and other services related to your health care. An example of treatment would be consulting with another health care provider, such as family physician or another therapist.

○ Payment is obtained reimbursement for your health care. We may disclose PHI to the health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

○ Health Care Operations are activities that relate to the performance and operation of this practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

● “Use” applies only to activities within the office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

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● “Disclosure” applies to activities outside of this office such as releasing, transferring, or providing access to information about you to others.

● “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form

II. Other Uses and Disclosures Requiring Authorization

We may use or disclose PHI for other purposes than treatment, payment, or health care operations(TPO) when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. You will revoke all such authorizations (of PHI) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures Not Requiring Consent or Authorization We may use or disclose PHI without your consent or authorization in the following circumstances:

● Child Abuse – If I have reasonable cause to suspect or believe that any child under the age of eighteen years (1) has been abused or neglected, (2) has had non-accidental physical injury, or injury which isn’t consistent with the history given of the injury, or (3) is placed at imminent risk of serious harm, then we are required by law to report this suspicion or belief to the appropriate authority.

● Adult and Domestic Abuse – If we know or in good faith suspect that an elderly individual or an individual, who is disabled or incompetent, has been abused, we may disclose the appropriate information as permitted by law.

● Health Oversight Activities – If a professional oversight organization is investigating this practice, they may subpoena records relevant to such investigation.

● Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records, this information is privileged under state law, and we will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

● Serious Threat to Health or Safety – If we believe in good faith that there is risk of imminent personal injury to you or to other individuals or risk of imminent injury to the property of other individuals, we may disclose the appropriate information as permitted by law.

● Worker’s Compensation – We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s 4 of 5 compensation or other similar programs, established by law, that provide benefits for work related injuries or illness without regard to fault.

IV. Client’s Rights and Therapist’s Duties Client’s Rights: Patient Rights

● Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.

● Right to Receive Confidential Communications by Alternative Means and at Alternative Location – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are attending this clinic. On your request, we will send your bills to another address.)

● Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in our health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this

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decision reviewed. On your request, we will discuss with you the details of the request and denial process.

● Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

● Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, we will discuss with you the details of the accounting process.

● Right to a Paper Copy – You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.

● Therapist’s Duties: We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. 5 of 5.

● We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.

● If we revise our policies and procedures, we will notify you by U.S. mail or in person during our session. When information is disclosed, we will disclose the minimum amount of information necessary to address the reason the information was requested.

V. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Heather Arnt or Kelli Ellenbaum. They can be reached at 701-222-3175. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The Privacy Officer can provide you with the appropriate address upon request.

VI. Effective Date This notice will go into effect on September 15, 2009.

Summary Notice of HIPPA Privacy PracticesWe may share your health information to: treat you, get paid, run the clinic, tell you aout other health benefits/services, raise funds, tell family and friends about you, do research, health and safety reasons, military purposes, workman’s comp requests, lawsuits, law enforcement, national security reasons, coroner, medical examiner or funeral director use.

YOU HAVE THE RIGHT TO: get a copy of your medical record, change your medical record if you think it is wrong, get a list of whom we share your health information with, ask us to limit the information we share, ask for a copy of our privacy notice, and complain in writing to the clinic if you believe your privacy rights have been violated.

INDIVIDUAL AUTHORIZATION FOR USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your written authorization before we may use or disclose your protected health information for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information may be used or disclosed. Please read the information below carefully before signing this form.

Patient Name: _____________________________________________________

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Parent/Guardian/Legal representative of Patient:

_____________________________________________________Date:__________________________

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