Assessment and Therapy Associates of Grand Forks, PLLC
725 Hamline Street
Grand Forks, North Dakota 58203
(701) 780-6821 (phone) (701) 780-1973 (fax)
PEDIATRIC BACKGROUND INFORMATION FORM
Last Name: Age: Child‟s First Name: Date of Birth:
Name of Parent(s)/Guardian: (mother): (father):
Name of Person Completing This Form: Relationship to Child:
Do you have legal custody of this child? Yes No
City: State: Zip: Address: Street:
Phone: Home: ( ) - Work: ( ) - Cell/Other: ( ) -
May we leave messages at: Home? Yes No Work? Yes No Cell? Yes No
E-mail Address (if you would like to use this for communication):
How were you referred to this clinic?
Who is your child‟s primary care physician/provider?
Would you like a copy of this evaluation sent to your child‟s physician/provider? Yes No
If yes, where does this provider practice (i.e., name/address of clinic):
(Please give your insurance card to the office manager)
Person responsible for bill: Date of Birth: Relationship to patient:
Home phone no.: ( ) - Address of responsible party (if different):
Is this patient covered by insurance? Yes No Name of Insurance Company/Plan:
Subscriber‟s name: Plan Number/ID: Group Number:
Patient‟s relationship to subscriber: Self Child Other Subscriber‟s Date of Birth:
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the clinician. I understand that I am financially responsible for any balance. I also authorize Assessment and Therapy Associates of Grand Forks,
PLLC or insurance company to release any information required to process my claims (please initial):
Please describe the problems that your child is demonstrating:
How long have these problems been present?
Are these problems related to any specific event or situation? Yes No
If yes, describe the event/situation:
Is your child currently in therapy for these problems? Yes No If yes, who is the therapist? Does your child currently take medication(s) for this or any other emotional or behavioral problem? Yes No If yes, what medication(s) does he/she take? Who manages this medication?
If your child is being seen for an assessment, what questions would you like to have answered?
Has your child had therapy previously? Yes No If yes, who was therapist? What problems did previous therapy address?
Has your child previously taken any medication(s) for this or any other emotional or behavioral problem? Yes No If yes, what medication(s) did he/she take? Who managed this medication?
Has your child ever been evaluated for learning, developmental, emotional, or behavioral issues? Yes No If yes, what types of evaluation(s) has your child had (CHECK AND DESCRIBE ALL THAT APPLY):
Emotional/Behavioral Problems Who conducted evaluation?
Cognitive/Learning Evaluation Who conducted evaluation?
Developmental Delays Who conducted evaluation?
Speech/Language Problems Who conducted evaluation?
Fine or Gross Motor Who conducted evaluation?
Sensory Integration Who conducted evaluation?
Visual Processing Evaluation Who conducted evaluation?
Central Auditory Processing Who conducted evaluation?
Other (Describe): Who conducted evaluation?
Did your child have any of the following problems? PLEASE CHECK AND DESCRIBE ALL THAT APPLY
Prenatal problems If yes, describe:
Alcohol or drug exposure in utero If yes, describe:
Delivery problems If yes, describe:
Caesarian Section Delivery Reason for C-Section:
Prematurity If yes. how early was child delivered?
Health problems at birth If yes, describe:
What was your child‟s birth weight? pounds ounces
Has your child had any of the following medical problems? PLEASE CHECK AND DESCRIBE ALL THAT APPLY
Chronic Ear Infections Age infections began: Ear Tubes Age ear tubes were placed:
Chronic medical issues If yes, describe:
Seizures If yes, describe:
Prolonged high fevers If yes, describe:
Head injury If yes, describe:
Surgeries If yes, describe:
Serious Medical Illnesses If yes, describe:
Does your child currently take any medications for health problems? Yes No If yes, what medications?
What are medications for?
Does your child have any of the following problems with sleep (CHECK ALL THAT APPLY):
severe resistance to going to bed problems falling asleep once in bed
sleeping less than usual (WITH daytime fatigue) sleeping less than usual (WITHOUT daytime fatigue)
sleeping too much waking in the night
waking too early in the morning
Does your child have any of the following appetite or eating problems (CHECK ALL THAT APPLY):
excessively picky eating eating too little
eating too much trying to lose weight when weight is normal Has you child recently gained a significant amount of weight? Yes No If yes, how much? Has you child recently lost a significant amount of weight? Yes No If yes, how much?
Has your child had developmental delays in any of these areas? PLEASE CHECK AND DESCRIBE ALL THAT APPLY
Gross (large) motor skills If yes, describe:
Fine (small) motor skills If yes, describe:
Language skills If yes, describe:
Self-help skills If yes, describe:
Social skills If yes, describe:
Other delays If yes, describe:
What hand does your child use? Right hand Left hand Both Has not chosen dominant hand
Does your child demonstrate any of the following behaviors or problems (CHECK ALL THAT APPLY):
tics lack of imaginative play
unusual movements poor response to changes or transitions
speaking “her own language” disinterest in people/peers
poor eye contact unusual interests or attachment objects
“echoing” or repeating what he/she hears problems talking about things other than his/her interests
repeating movies/conversations oversensitivity to sounds
not responding to his/her name when called seeking out loud sounds or noises
difficulty imitating others oversensitivity to visual stimuli
hand flapping or other unusual behavior when excited oversensitivity to touch
walking on his/her toes high pain tolerance
waving fingers or other objects in front of his/her face oversensitivity to smells
lining up toys in play oversensitivity to food textures
Describe your child‟s friendships and peer relationships:
Describe your child‟s strengths:
Where does your child live (city, state)? Who does child live with?
Mother‟s name: Mother‟s occupation: Child‟s relationship with mother:
Father‟s name: Father‟s occupation: Child‟s relationship with father:
Other Caregivers (e.g., step-parents): Child‟s relationship with caregivers:
List child’s siblings below:
Name: Age: Child‟s relationship with this sibling: Name: Age: Child‟s relationship with this sibling: Name: Age: Child‟s relationship with this sibling: Name: Age: Child‟s relationship with this sibling: Have any of the following stressors impacted your child in the last year?
Divorce Death of parent Death of family member
Death of friend Starting new job Abuse/victim of crime
Victim of accident Serious illness Illness of family member
Conflict in family Financial problems Illness in close friend
Conflict with friends Death of a pet Foster home placement
Expelled from school Birth of a child Separation from family
Break-up of relationship Conflict at work Moving to a new area
Natural disaster Surgeries Separation Provide further description of family stressors (if needed):
List any family medical problems that your child is at risk for:
Family Psychiatric History (CHECK ALL THAT APPLY):
Depression Bipolar Disorder (Manic-Depression) Anxiety/nervousness
Panic Attacks Schizophrenia Suicide Attempts
Alcohol problems Drug problems Suicide Completion
Learning Problems Attention Problems Legal Problems
Autism Hyperactivity Delayed Development
Eating Disorders Hospitalization for mental problems Tics/Tourette‟s Syndrome
What grade is your child in currently? What school does your child attend? Who is your child‟s teacher (if child is in middle or high school and has multiple teachers, enter “team”): Does child currently have problems in any of the following academic areas? CHECK AND DESCRIBE ALL THAT APPLY
Reading problems If yes, describe:
Writing problems If yes, describe:
Math problems If yes, describe:
Behavior problems (at school) If yes, describe:
Homework problems If yes, describe:
Does your child have an Individualized Education program (IEP)? Yes No If yes, what does programming address?
Speech/language problems Specific Learning Disability Autism
Noncategorical Delay Mentally Handicapped Emotional/Behavioral Problems
Other Health Impaired Traumatic Brain Injury Other (describe) Does your child have a 504 Accommodation Plan? Yes No If yes, what do accommodations address?
attention/organizational problems fine motor problems emotional problems
behavioral problems sensory problems other (describe): Has your child ever been retained (held back) in a grade? Yes No If yes, why?
Attention Problems (CHECK ALL THAT APPLY):
fails to give close attention to details becomes easily distracted by extraneous stimuli
makes careless mistakes in schoolwork has difficulty refocusing after distraction
has difficulty sustaining attention in tasks or play has difficulty following through on instructions
demonstrates poor listening when spoken to directly fails to finish work
avoids tasks that require sustained mental effort has difficulty with multitasking Organization Problems (CHECK ALL THAT APPLY):
generally messy has many missing assignments
loses things necessary for tasks forgetful in daily activities
forgets to turn work in forgets to bring home homework Activity Level Problems (CHECK ALL THAT APPLY):
fidgets or squirms in his/her seat often has difficulty playing quietly
leaves her seat in the classroom or in other situations is „on the go‟ or often acts as if „driven by a motor‟
runs about or climbs excessively talks excessively
reports feeling restless
Impulse Control Problems (CHECK ALL THAT APPLY):
blurts out answers to questions interrupts or intrudes on others
has difficulty awaiting her turn behaves in a way that could be dangerous because she does not think through her actions
Other Behavioral Problems (CHECK ALL THAT APPLY):
often blames others for her own mistakes or misbehavior is often angry or resentful
steals at home has anger management problems
steals outside of home often loses her temper uses alcohol/drugs has temper tantrums has trouble with the law argues with adults
defies and refuses to comply with adults‟ requests or rules
How long have the behavioral problems you checked above existed?
Depressive Symptoms (CHECK ALL THAT APPLY):
excessive, frequent sadness and crying excessive physical complaints
poor self-esteem energy loss/excessive fatigue
excessive or frequent irritability loss of interest in activities
overreactions to events social withdrawal
extreme mood swings suicidal thoughts/behavior ANXIETY SYMPTOMS (CHECK ALL THAT APPLY)
specific fears obsessive thoughts
general worry about what is going to happen repetitive acts
worry about family members fear of public places
worries about school fear of social interaction
panic attacks (i.e., racing heart, extreme fear)
How long have the emotional problems you checked above existed?
Are the above describe emotional and/or behavioral problems related to a specific situation/event? Yes No If yes, describe:
What questions would you like to have answered as a result of this evaluation?
Is there anything else you feel we should know about your child?
Assessment and Therapy Associates of Grand Forks
Pediatric Psychology Services Patient Contract
Providers of Service: Psychological Services at Assessment and Therapy Associates of Grand Forks are provided by a licensed clinical psychologist, a post-doctoral resident, a psychology technician (i.e., testing) or a psychology intern. Post-doctoral residents
have their Ph.D. in clinical psychology and are currently being supervised by a licensed psychologist in preparation for independent
licensure. Psychology interns are advanced graduate students from the University of North Dakota who have their Master‟s Degree
in psychology and are working toward their doctorate. Interns also work under the supervision of a licensed psychologist.
Confidentiality: Discussions with your psychology care provider are confidential unless you (i.e., the child‟s legal custodial parent/guardian) grant written permission to release this information. In order to submit insurance claims, your insurance company
needs to be aware that your child is receiving services and they will require disclosure of your child‟s diagnosis. If you plan to have
claims submitted to an insurance company, by signing this form you consent to have your child‟s diagnostic information provided to
your insurance company at the time of billing for services. Your insurance company may also request additional records; however,
these records will not be released to your insurance company or any other third party until we have obtained your written permission.
There are three exceptions to this promise of confidentiality that do not require written permission: (1) instances of suspected child
abuse or neglect; (2) instances in which a patient threatens to harm him/herself; and (3) instances in which a patient threatens to
harm another person. In these cases your care provider has an ethical and legal obligation to report this information to the appropriate parties/agencies.
Contacting Your Doctor During Normal Business Hours: If you or your child needs to contact your care provider during normal business hours, you can call Assessment and Therapy Associates of Grand Forks at (701) 780-6821. Your mental health care provider will return your call as soon as possible. In the case of an emergency, it is advised that you call 911, go to the Emergency
Department at Altru Hospital, or call the 24-hour crisis line at Northeast Human Service Center at (701) 775-0525.
Contacting Your Doctor on Evenings and Weekends: In the case of an emergency, it is advised that you call 911, go to the Emergency Department at Altru Hospital, or call the 24-hour crisis line at Northeast Human Service Center at (701) 775-0525.
Billing and Payment: Licensed Psychologists and post-doctoral residents are considered providers of medical services for most insurance companies. It is important that you check with your insurance company to determine what services are covered, because
payments and restrictions vary with each company. It is strongly encouraged that you pay for services at the time of your appointment.
Missed Appointments: Assessment and treatment involve considerable commitments of time, effort, and cost for you, your child, and your service provider. In order for assessment and treatment to be successful, it is important to maintain appointments. If
changes to the original assessment or treatment plan need to be made, this can be discussed with your mental health care provider
and the plan can be revised to meet scheduling needs. If you are unable to come for an appointment, it will be expected that you
call to reschedule at least 24 hours in advance of your missed appointment. If two consecutive appointments are missed without
prior notification, our business office may cancel all previously scheduled appointments with your mental health care provider.
I have read and understand this contract and agree to the terms and conditions stated. In addition, I agree that I am truthfully
representing myself as the legal custodial parent/guardian of this child.
Child‟s Name Child‟s Birthday
Signature of Responsible Party Date
Assessment and Therapy Associates of Grand Forks, PLLC
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.
ATAGF. Uses and Disclosures for Treatment, Payment, and Health Care Operations
ATAGF 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”
– Treatment is when ATAGF clinicians provide, coordinate, or manage your health care and other services related to your health
care. An example of treatment would be when your doctor or therapist consults with another health care provider, such as your
family physician or another doctor or therapist.
– Payment is when ATAGF obtains reimbursement for your healthcare. Examples of payment are when ATAGF discloses your
PHI to your 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 our 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 my office, such as sharing, employing, applying, utilizing, examining, and analyzing
information that identifies you.
; “Disclosure” applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to
; “Psychotherapy Notes” are notes your doctor or therapist has made about your conversation during an assessment interview private,
group, joint, or family counseling session, which your doctor or therapist has kept separate from the rest of your medical record.
These notes are given a greater degree of protection than PHI.
II. Uses and Disclosures Requiring Authorization
ATAGF may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when ATAGF is asked for information for purposes outside of treatment, payment, or health care
operations, ATAGF will obtain an authorization from you before releasing this information. ATAGF will also need to obtain an authorization before releasing your Psychotherapy Notes.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may
not revoke an authorization to the extent that (1) ATAGF has
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 with Neither Consent nor Authorization
A psychologist may use or disclose PHI without your consent or authorization in the following circumstances:
; Child Abuse – If a psychologist is treating a child and knows or suspects that child to be a victim of child abuse or neglect, the
doctor or therapist is required to report the abuse or neglect to a duly constituted authority.
; Adult and Domestic Abuse – If a psychologist has reasonable cause to believe an adult, who is unable to take care of himself or
herself, has been subjected to physical abuse, neglect, exploitation, sexual abuse, or emotional abuse, the psychologist must
report this belief to the appropriate authorities.
; Health Oversight Activities – If the North Dakota Board of Psychologist Examiners is conducting an investigation into a
psychologist’s practice, then the psychologist may be required to disclose PHI upon receipt of a subpoena from the Board.
; 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 thereof, such information is privileged under state law, and your psychologist will
not release information either without your written authorization, the authorization of your legally appointed representative, or a