CURRENT REASON FOR SEEKING TREATMENT
CHEMICAL USE AND HISTORY
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.
ADOLESCENT INTAKE FORM (PARENT SECTION)
CURRENT HOUSEHOLD AND FAMILY INFORMATION
Current Reason For Seeking treatment For Your Adolescent.
PARENT’S MARITAL STATUS ( this question refers to the biological parents relationship)
(Please answer the following as best as you can, we understand that you may not be able to answer some of the questions pertaining to the other parent.)
*Please answer if you are no longer with your child’s bio-mother OR check here if you are still with bio-mother___________
*Please answer if you are no longer with your child’s bio-father OR check here if you are still with bio-mother___________
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.
Brain Health USA Center treats adults and children with depression, anxiety, ADHD, bipolar disorder, schizophrenia, autism, down syndrome, drug abuse, and PTSD.
August 11, 2022
August 9, 2022
Copyright by Brain Health USA 2019. All rights reserved.