CURRENT REASON FOR SEEKING TREATMENT
Adolescents (please answer the following with Y/N)
*We would like you to know that we have worked with a lot of adolescents and that we respect your privacy and we hope to create an atmosphere where you feel comfortable sharing.
CURRENT HOUSEHOLD AND FAMILY INFORMATION
Names,Relationship (parent, sibling, etc),Age,Sex,Type (bio, step, etc), Living with you? Y/N
Current Reason For Seeking treatment For Your Adolescent.
PARENT’S MARITAL STATUS ( this question refers to the biological parents relationship)
YOUR ADOLESCENT’S STRENGTHS
INDIVIDUAL CONCERNS YOU NOTICE REGARDING YOUR SON OR DAUGHTER
Special Confidentiality Notice for Parents
Your child has the right to private, confidential communication with the doctor, therapist, and treatment team providing his or her care. This means that some of the issues that they discuss will stay between them, and that we will not disclose that information to anyone, including you, unless we have been given permission by your child to do so. We need your child to be open and honest with us in order to understand and treat the full range of issues your child is dealing with, and they may be too scared, angry, or ashamed right now to share those issues with you. We also recognize it is very important for you to know what your child is going through in order to do your job as a parent, which is why we will always encourage your child to be honest with you. We will encourage, prepare and support your child so that they feel safe enough to share those issues with you.
According to State law, and the federal patient privacy law known as HIPAA, your child will need to give his/her consent for us to disclose:
· All Mental Health records for children age 16 or older.
· All information concerning pregnancy, sexual activity, STD’s, and drug/alcohol use or abuse, regardless of the child’s age.
· Any information that your child’s provider believes, if released, could cause harm to your child or to someone else, or that would significantly harm the treatment relationship with your child.
- You should know that this confidentiality has limits. If there is any threat to your child’s life, we have the duty to inform you and help to create a plan for safety.
- In addition, there are situations that we are mandated to report and cannot keep confidential. Those situations include: threats against another person, physical or sexual abuse, neglect, and pregnant women who report using drugs.
- Finally, we recognize how challenging it can be for a parent to raise a child, especially when the child has a mental illness. We know how badly you might want to know everything your child has kept a secret from you, too. We want to be your partner in supporting your child’s physical and mental wellbeing, and even when we can’t discuss certain details about your child with you, we will always be there for you: guiding you and giving your child the best advice possible to protect him/her and encourage healthy decisions, including being open and honest with you.