• School Age Youth

  • Sex
  • Education

  • General Health

  • General Physical Health
  • Are you currently taking any medication?
  • Have you ever used drugs for other than medicinal purposes?
  • Have you ever had psychotherapy or counseling before?
  • Have you experienced a severe emotional trauma?
  • Have you recently experienced the loss of someone close to you?
  • Descriptive Traits

  • Check any of the following words that seem to describe you:

  • Family and Living Situation

  • Are you presently living with your parents?
  • Are your parents separated or divorced?
  • Were either of your parents married before?

  • Mother
  • Father
  • Religious Information

  • What are your feelings toward the following?

  • Certain Waivers under HIPAA.

    (a) Patient acknowledges that neither Group nor Physician guarantees that communications with Physician using electronic mail ("e-mail"), facsimile, video chat, instant messaging, and cellular telephone are secure or confidential methods of communications. Accordingly, Patient expressly waives Group’s and Physician’s obligations under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all rules and regulations promulgated thereunder (collectively, "HIPAA"), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of patient-related information, to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of Patient’s medical records maintained by Physician.

    (b) By providing Patient’s e-mail address to Physician, Patient authorizes Physician to communicate with Patient by e-mail regarding Patient’s "protected health information" ("PHI") (as defined under HIPAA) and Patient understands and agrees to the following:

    1. E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI;
    2. Although Group and Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Group nor Physician can assure or guarantee the absolute confidentiality of such e-mail communications.
  • Today's Date*
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    2 digit month, 2 digit day, 4 digit year
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