Child Intake

Child Form 01/14 Demographics

Demographic Verification
Please choose which location you want your services…*
Guardian/Parent Name*
First Last
Guardian/Parent Suffix
Guardian/Parent Email
Enter Email Confirm Email
Guardian/Parent Social Security Number
Guardian/Parent Date of Birth*
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Social Security Number
Patient Date of Birth*

Child Form 02/14 Intake Procedures

Intake Procedures
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Date of Birth*
Hidden
Email
Enter Email Confirm Email
Intake Procedure*
Welcome to TEAMCare Behavioral Health, LLC. We are pleased that you have chosen our agency to help you address your mental health related needs. The purpose of this document is to inform you of our intake procedures.

Each new client who comes to TEAMCare Behavioral Health, LLC must take part in our intake process. This is the first step in accessing services through our agency. The purpose of the intake process is for our staff to conduct a thorough assessment of your referral concerns and determine which mental health services will best meet your needs. When you come in for your intake, you will meet with a clinician who will ask you a series of questions related to your reasons for accessing services, background in a variety of life domains, your mental health and other treatment history, current and history of medication use, and current and past mental health related concerns.

At the conclusion of your intake, the clinician will inform you of what services will best meet your needs and help you to set up those services through our agency. If the service that will best meet your needs is not one provided through our agency, your intake clinician will ensure every effort is made to refer you to an alternative provider or provide information that will help you to access the needed service.

By checking the box below that states “I agree to the Intake Procedure” you, the Guardian/Parent, agree that you have read our Intake Procedure and understand it.

I agree to the intake procedure.
Guardian/Parent Printed Name Signing Consent*
First Last
Guardian/Parent Printed Name Suffix

Child Form 03/14 Freedom of Choice

Freedom of Choice Statement
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Date of Birth*
Consent*
By checking the box below, I am stating that I am aware that I have a choice of providers available to me, and that outpatient services are provided by the following providers in Lancaster County:

Behavioral Healthcare Consultants
1755 Oregon Pike
Lancaster, PA 17601
717-581-5255

Community Services Group, Inc.
CSG – MAPS Outpatient
790 New Holland Avenue
Lancaster, PA 17602
717-390-0353

TEAMCare Behavioral Health, LLC
5570 Derry Street
Harrisburg, PA 17111
(717) 525-9804

Pennsylvania Counseling Services, Inc.
20B East Rossville Rd
Lancaster, PA 17601
717-560-2372

Nuestra Clinica of SACA, Inc.
445 East King Street
Lancaster, PA 17602
717-431-0830

T.W. Ponessa & Associates, Inc.
410 N Prince St.
Lancaster, Pa 17603
717-560-7917

I agree that I have received the Freedom of Choice Statement.
Guardian/Parent Printed Name*
First Last
Guardian/Parent Printed Name Suffix
Guardian/Parent Date of Birth*
Email*

Child Form 04/14 Financial Responsibility

Financial Responsibility & Release
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Date of Birth*
Patient Social Security Number*
Charges for services provided by TEAMCare Behavioral Health, LLC (“the Clinic”) cover the following components: Intake interview, psychiatric evaluation, nursing services, psychotherapy, medication management and/or psychological testing. We require payment of the client’s copay or deductible amount, if applicable, on the date of your service. If you are unable to pay this amount in full on the day of service, a $10.00 service charge will be added to the client’s account and an invoice will be mailed to you for the full amount due. Payment on this invoice is due within 15 days of the date of service. We will submit a claim to the client’s insurance carrier within one week of receiving complete billing information. The client will be notified by his/her insurance company when final action (payment, denial, etc.) for the claim has been processed. If any additional funds are owed, you will be invoiced for the full remaining balance due. Payment in full is due within 15 days of the date printed on the invoice. A service charge of $35.00 will be added to the client’s account for any returned checks due to non-sufficient funds and/or stop payment. In the event that a past due account is submitted to a collection agency, you agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs and expenses, including reasonable attorneys’ fees, we incur in such collection efforts. We file the insurance claim for the client as a courtesy for the client; however, our relationship is with the client, not the insurance company. It is the client’s responsibility, or in the case of a minor it is the parent/guardian’s responsibility, to be knowledgeable regarding the insurance coverage and benefits. We expect full cooperation from the client and responsible party in obtaining payment from the insurance company. If difficulties arise that go unresolved for 60 days, the balance on the claim, with certain exceptions, will become your responsibility to pay in full. An invoice will be mailed to you, and payment will be due within 15 days of the date printed on the invoice. ASSIGNMENT OF INSURANCE BENEFITS I hereby authorize direct payment to TEAMCare Behavioral Health, LLC of any medical and/or procedural insurance benefits otherwise payable to me or on my behalf for the service(s) performed at the Clinic, at a rate not to exceed the Clinic’s regular charges. This assignment of benefits is valid for all insurance companies and programs including Medical Assistance, private and group insurance, workers’ compensation or other health plan payments.*
Charges for services provided by TEAMCare Behavioral Health, LLC (“the Clinic”) cover the following components: Intake interview, psychiatric evaluation, nursing services, psychotherapy, medication management and/or psychological testing. We require payment of the client’s copay or deductible amount, if applicable, on the date of your service. If you are unable to pay this amount in full on the day of service, a $10.00 service charge will be added to the client’s account and an invoice will be mailed to you for the full amount due. Payment on this invoice is due within 15 days of the date of service.

We will submit a claim to the client’s insurance carrier within one week of receiving complete billing information. The client will be notified by his/her insurance company when final action (payment, denial, etc.) for the claim has been processed. If any additional funds are owed, you will be invoiced for the full remaining balance due. Payment in full is due within 15 days of the date printed on the invoice. A service charge of $35.00 will be added to the client’s account for any returned checks due to non-sufficient funds and/or stop payment. In the event that a past due account is submitted to a collection agency, you agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs and expenses, including reasonable attorneys’ fees, we incur in such collection efforts.

We file the insurance claim for the client as a courtesy for the client; however, our relationship is with the client, not the insurance company. It is the client’s responsibility, or in the case of a minor it is the parent/guardian’s responsibility, to be knowledgeable regarding the insurance coverage and benefits. We expect full cooperation from the client and responsible party in obtaining payment from the insurance company. If difficulties arise that go unresolved for 60 days, the balance on the claim, with certain exceptions, will become your responsibility to pay in full. An invoice will be mailed to you, and payment will be due within 15 days of the date printed on the invoice.

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize direct payment to TEAMCare Behavioral Health, LLC of any medical and/or procedural insurance benefits otherwise payable to me or on my behalf for the service(s) performed at the Clinic, at a rate not to exceed the Clinic’s regular charges. This assignment of benefits is valid for all insurance companies and programs including Medical Assistance, private and group insurance, workers’ compensation or other health plan payments.

I agree to the Financial Responsibility
Guardian/Parent Printed Name*
First Last
Guardian/Parent Printed Name Suffix
Guardian/Parent Date of Birth*
Guardian/Parent Social Security Number*
Email*

Child Form 05/14 Parental Consent

Guardian/Parent Consent
Consent of both parents/guardians may be required for treatment
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Date of Birth*
1. Do you have the Legal Right to Consent to Medical Decisions for this Member?*
- Yes
- No
2. Is there a current Custody Agreement that outlines your Parental Rights?*
- Yes
- No
Documentation may be required.
Guardian/Parent Printed Name*
First Last
Guardian/Parent Printed Name Suffix
Guardian/Parent Date of Birth*
Hidden
Email

Child Form 06/14 Informed Consent

Informed Consent
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Date of Birth*
Consent*
After reading this carefully, please indicate your understanding and consent by checking the box below, stating that you, the Guardian/Parent of the child provide consent of treatment. If you have any questions, please feel free to discuss them with the psychologist/therapist. Your signature below serves as Authorization for outpatient services. These services may involve psychological/psychiatric evaluation and testing, medication management, and/or therapy. This Authorization has been made freely and voluntarily.

Confidentiality

All information you share about yourself will be kept confidential and secure as per the Federal Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Health Information Technology for Economic and Clinical Health (HITECH) Act, and the Pennsylvania Mental Health Procedures Act (PA Code Title 55, Chapter 5100). Without your written permission, no information will be released to anyone outside of this agency. The only exceptions to this policy are situations involving imminent danger to you (client) or someone else, suspicion of child abuse, or possibly, if the information is mandate by court order.

As applicable, information will also be shared with the supervising licensed psychologist/psychiatrist reviewing the final report or treatment plan. The current clinician has obtained their Master’s or Doctoral Degree in Psychology/Psychiatry and, if not licensed, is currently practicing under the supervision of a licensed psychologist or psychiatrist. Should you have any concerns please contact the appropriate office listed above.

Policy on Review of Evaluation Results

Comprehensive psychological testing is a lengthy process. Tests of this nature are designed to provide results which will help address the long-term needs of the member for identified behaviors and not for determining the immediacy of services. Results may take more than 60 days to complete as testing may require multiple face-to-face sessions in addition to detailed analysis of complex score data.

Because a psychological/psychiatric evaluation provides considerable information on the behaviors and level of functioning of an individual, we encourage the client, or parent(s)/guardian(s) in case of a child, to review the results with a psychologist/psychiatrist. This will provide an opportunity for you to discuss issues and questions surrounding the evaluation results.

Further, it is the policy of this provider, that, in order for release of the written psychological/psychiatric evaluation reports to the client, or parent(s)/guardian(s), an in-person or phone consultation involving review of the evaluation results must occur.

I agree to the Informed Consent.
Guardian/Parent Printed Name*
First Last
Guardian/Parent Printed Name Suffix
Guardian/Parent Date of Birth*
Hidden
Email

Child Form 07/14 PHI Disclosure

Protected Health Information (PHI) Disclosure
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Date of Birth*
Consent*
This form is an agreement between you [name indicated above] and TEAMCare Behavioral Health, LLC. When we use the word “you” below, it will mean you, your child, relative, or other person, if you have written his or her name above.

When we evaluate, diagnose, treat, or refer you, we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information here to decide on what treatment is best for you, and to provide treatment to you. We may also share this information with others who provide treatment to you, or need it to arrange payment for your treatment, or for other business or government functions.

By checking the box below of this form, you are agreeing to let us use your information here and send to others. The Notice of Privacy Practices explains in more detail your rights and how we can use and share your information. Please read this before you agree to the Consent form.

If you do not agree to this Consent form agreeing to what is in our Notice of Privacy Practices, we cannot evaluate/treat you.

In the future, we may change how we use and share your information, and so may change our Notice of Privacy Practices. If we do change it, you can get a copy by calling any of our TEAMCare Offices.

If you are concerned about some of your information, you have the right to ask us not to use or share some of your information for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to comply with your wish.

After you have agreed to this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on, but we may already have used or shared some of your information and cannot change that.

I agree to the PHI Disclosure.
Guardian/Parent Printed Name*
First Last
Guardian/Parent Printed Name Suffix
Guardian/Parent Date of Birth*
Hidden
Email

Child Form 08/14 No Show Cancellation Policy

Cancellation/No-Show Policy
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Date of Birth*
Consent*
For the purposes of this policy, a “No Show” includes not showing up for your scheduled appointment, showing up for your appointment but refusing treatment, or cancelling your appointment within 24 hours of the scheduled time. In addition, showing up late for your appointment may be considered a “No Show” if the physician or therapist is unable to accommodate your appointment.

For new patients:

If you miss your first appointment with the doctor or therapist after your initial intake appointment, you will be discharged immediately and will need to seek services at another agency.

For established patients:

1st time: You will be charged $40.00 for the missed appointment which must be paid prior to your next scheduled appointment. Be advised that insurance companies do not pay for missed appointments, so you will be fully responsible to pay the $40.00 charge.

2nd time: We will send you a notice alerting you that you have missed a second appointment. This notice will also direct you to call our office within 14 days to reschedule or you will be asked to seek services at another agency. You will also be charged $40.00 for the missed appointment which must be paid prior to your next scheduled appointment. Be advised that insurance companies do not pay for missed appointments, so you will be fully responsible to pay the $40.00 charge.

3rd time: We will send you a final notice stating that you have been discharged from services and will need to seek your services from another agency. You will also be charged $40.00 for the missed appointment. Be advised that insurance companies do not pay for missed appointments, so you will be fully responsible to pay the $40.00 charge.

By clicking the box, “I agree to TEAMCare’s No Show Policy” you agree that you have read and understand the terms of this policy, and whomever is named as the financially responsible person will be responsible for paying any no show/cancellation fees.

I agree to the No-Show/Cancellation Policy.
Guardian/Parent Printed Name*
First Last
Guardian/Parent Printed Name Suffix
Guardian/Parent Date of Birth*
Hidden
Email

Child Form 09/14 OPMHS Agreement

Outpatient Mental Health Service/Attendance Agreement
In order to provide the most effective Outpatient Mental Health Services (OPMHS), TEAMCare requires all patients or their parents/guardians to be an active part of the treatment process. We also require that you provide our agency with your current contact information by completing the following section of this agreement:
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Date of Birth*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Please continue through this document to complete the Service/Attendance Agreement: For your review you have been given a copy of TEAMCare’s Outpatient Mental Health Service Attendance Policy for your review. We further request that you complete the following Service agreement to signify your understanding and acceptance of our attendance expectations.
On this date*
That I,
First Last
Consent*
acknowledge that I have been provided with a copy of the TEAMCare Behavioral Health, LLC’s Outpatient Mental Health Service Attendance Policy. I have also been given ample opportunity to read and review the terms of this policy. I agree to fully comply with the terms outlined within this policy affirmed by my signature at the end of this agreement.

TEAMCare reserves the right to terminate Outpatient Mental Health Services in part or in whole upon notification provided to the patient or as a result of but not limited to the breach of this agreement by the patient. The patient also reserves the right to terminate receiving Outpatient Mental Health Services in part or in whole at any time from TEAMCare Behavioral Health, LLC upon notification to said agency.

I agree to the OPMHS Service/Attendance Agreement.
Guardian/Parent Printed Name*
First Last
Guardian/Parent Printed Name Suffix
Guardian/Parent Date of Birth*
Would you like a copy of this form for your records?*
- Yes
- No
Please choose how you would like to receive a copy…*
- Receive in Person (if appt is not Telehealth)
- Mail a copy to me please
- Email a copy to me please
Email*

Child Form 10/14 Overweight Risk Assessment

Child Overweight Risk Assessment
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Date of Birth*
Instructions for this form.
Through these questions, please read the full question carefully. After reading the question, if you feel that the answer is “Yes” please indicate your answer with a 1 in the field. If you feel that the answer is “No” please indicate your answer with a 0 in the field.
1. Does your child prefer to watch television or videos, play video or computer games, or surf the web over other activities.*
2. Does your child drink a lot of high sugar drinks, such as soda and juice?*
3. Is dinner often unplanned, where family members eat at different times, choose their own foods, or eat in front of the TV?*
4. Does your child often skip dinner because he/she is not hungry or eats very little dinner?*
5. Do you reward your child with food, especially sweets, for good behavior?*
6. Do you assume your child will lose their ‘baby fat’ as they get older or when they have a growth spurt?*
7. Do you believe a person’s weight problems are genetic and cannot be controlled with diet and exercise?*
8. Is the child’s mother or father overweight?*
Total number of "Yes"
Interpretation:

0-2 ‘Yes’ answers:
Your child’s overweight risk is low. A child’s overweight risk can change as their eating and activity habits change. Learn the overweight risk factors and encourage changes of your child develops any risk factors.

3-4 ‘Yes’ answers:
Your child’s overweight risk is moderate. You can help your child lower their overweight risk by slowly introducing them to a more active lifestyle and healthier eating habits.

5+ ‘Yes’ answers:
Your child’s overweight risk is high. Help your child lower their overweight risk by slowly introducing them to a more active lifestyle and healthier eating habits.

These assessments should be used for education about medical conditions only and are not for providing medical diagnosis. Only a health care professional can diagnose and recommend treatment. You are advised to promptly check with a physician if a medical condition exists or is suspected.
Hidden
Email

Child Form 14/14 Encounter Form

Encounter Form
Patient First Name*
Patient Last Name*
Patient Suffix
Patient Date of Birth*
Guardian/Parent Printed Name
First Last
Guardian/Parent Printed Name Suffix
Hidden
Email
Consent*
TEAMCare Behavioral Health requires patients sign an Encounter Form after each appointment. Typically, the encounter forms are signed using an electronic signature pad. The encounter form signifies that you received services from our agency and each signature is connected to the service or services you received the date of the signature.

In addition, if you are a patient using Medicare and / or Medicaid, it is of note that when you sign an Encounter Form using an electronic signature pad, you are agreeing to the following:

I certify that the information shown on this invoice is true, correct, and accurate. I understand that payment and satisfaction of this claim will be from federal and state funds, and that any false claims, statements or documents, or concealment of material facts, may be prosecuted under applicable federal and state laws

I agree to the Encounter Form Policy.

Child Intake

Child Form 01/14 Demographics

Demographic Verification

Child Form 02/14 Intake Procedures

Intake Procedures

Child Form 03/14 Freedom of Choice

Freedom of Choice Statement

Child Form 04/14 Financial Responsibility

Financial Responsibility & Release

Child Form 05/14 Parental Consent

Guardian/Parent Consent

Consent of both parents/guardians may be required for treatment

Child Form 06/14 Informed Consent

Informed Consent

Child Form 07/14 PHI Disclosure

Protected Health Information (PHI) Disclosure

Child Form 08/14 No Show Cancellation Policy

Cancellation/No-Show Policy

Child Form 09/14 OPMHS Agreement

Outpatient Mental Health Service/Attendance Agreement

Child Form 10/14 Overweight Risk Assessment

Child Overweight Risk Assessment

Instructions for this form.

Child Form 11/14 SDQ P4-10

Strength & Difficulties Questionnaire

Do the difficulties interfere with your child's everyday life in the following areas?

Child form 12/14 SCARED

Screen for Child Anxiety Related Disorders

Child Form 13/14 ODD Behavioral Rating Scale

ODD Behavioral Rating Scale

Child Form 14/14 Encounter Form

Encounter Form