Children and Teens

1
NameFull name of person completing this form
First Name
Last Name
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Your Relationship to the Child
3
Your Email Address
example@example.com
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Your Phone Number
Area Code
Phone Number
5
Child's Name
First Name
Last Name
6
Child's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Child's Date of Birth
Date
Year
Month
Day
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Child's Age
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
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Child's Grade
ECC Toddler
ECC Three's
Pre-K
Primer
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
High School Freshman
High School Sophomore
High School Junior
High School Senior
College Freshman
College Sophomore
College Junior
College Senior
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What school does the child currently attend?
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List all other schools the child has attended
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Parent 1's Name
First Name
Last Name
13
Parent 1's Email Address
example@example.com
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Parent 1's Phone Number
Area Code
Phone Number
15
Parent 2's Name
First Name
Last Name
16
Parent 2's Email Address
example@example.com
17
Parent 2's Phone Number
Area Code
Phone Number
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Does the child live with both parents?
YESNO
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If no, what is the custody agreement?
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Large
Normal
Small
Ok
Ok
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Who else lives in the home with the child?
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Large
Normal
Small
Ok
Ok
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Please describe your reason for seeking Shine Bright's services at this time.
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Large
Normal
Small
Ok
Ok
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Is the child currently taking medication?
YESNO
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If yes, what is the name of the medication and the prescribing doctor?
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Has the child ever completed an evaluation?
YESNO
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If yes, what was the evaluation for and what were the results?
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Large
Normal
Small
Ok
Ok
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Please check off any area(s) that you are concerned about at this time
Social Skills
Mood
Attention/Concentration
Behavior at Home
Behavior at School
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How did you hear about Shine Bright?
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Is there any other information that would be helpful at this time?
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Large
Normal
Small
Ok
Ok
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Consent to Treatment* This field is required.We are committed to providing you with quality care. Please take a few minutes to read the following information that will explain confidentiality and policies and procedures to you. If you have any questions, please ask and we will be happy to clarify any of the information in this form. Please sign and date this form acknowledging that you have read and fully understood the confidentiality and privacy information and are consenting to begin services. Thank you. Consent to Treatment: I, voluntarily, agree to receive or authorize an assessment, treatment or service and care and authorize Shine Bright Counseling and Counseling to provide such care, treatment or service as are considered necessary and advisable. I understand and agree that I will participate in the planning of the care, treatment or service and that I may stop such care, treatment or services that are provided but Shine Bright Counseling and Consulting. Emergencies: You may encounter a personal emergency that may require prompt attention. Your clinician will make reasonable efforts to respond to your emergency in a timely manner. If it is after-hours or on a weekend, or you reach the office voicemail during an emergency situation, please go to the nearest emergency room, and ask for assistance regarding a mental health emergency or call 911. Appointments: Services are by appointment only. You are responsible for keeping your appointment and timely arrival. In the event that you cannot keep an appointment, it is your responsibility to call/text your clinician at least 24 hours in advance to cancel or reschedule. No-shows or cancellations within 24 hours will be charged the regular session rate. Any type of audio/visual recording is prohibited in sessions, without prior discussion and consent. Confidentiality: You are protected by the confidentiality laws in Texas, which state that anything discussed during sessions and meetings is privileged information and cannot be shared with anyone else without your consent. This also means that we cannot tell anyone whether you are receiving services from Shine Bright Counseling and Consulting, PLLC without your permission. Possible exceptions to confidentiality include those provided by laws, including but not limited to child abuse, abuse, neglect, or exploitation of the elderly or the disabled; AIDS/HIV infection and possible transmission; criminal prosecution; child custody cases. These records are confidential pursuant to certain legal and ethical limits and clinical parameters, and the HIPAA Notice of Privacy Practices. Within these limits, the information revealed by you will be kept confidential. No information will be released without your written consent and authorization unless mandated by law. Possible legal exceptions to confidentiality include, but are not limited to, the following situations: · If you reveal information that indicates, you are a danger to yourself or someone else necessitating a duty to protect or duty to warn. · If you reveal information about child abuse, neglect, elder abuse or sexual exploitation. · If you are in therapy as the result of a court order, unless otherwise stated in the court order. · If I receive a subpoena or a court order to disclose information. · If you provide written permission or direction to release your record. If you have any questions or concerns regarding confidentiality, please discuss them with your Shine Bright counselor before signing this form. Consent to Treatment and Confidentiality: By signing this Client Information and Consent Form, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing, and I understand that I may stop such treatment or services, not under court order, at any time.
ClearWe are committed to providing you with quality care. Please take a few minutes to read the following information that will explain confidentiality and policies and procedures to you. If you have any questions, please ask and we will be happy to clarify any of the information in this form. Please sign and date this form acknowledging that you have read and fully understood the confidentiality and privacy information and are consenting to begin services. Thank you. Consent to Treatment: I, voluntarily, agree to receive or authorize an assessment, treatment or service and care and authorize Shine Bright Counseling and Counseling to provide such care, treatment or service as are considered necessary and advisable. I understand and agree that I will participate in the planning of the care, treatment or service and that I may stop such care, treatment or services that are provided but Shine Bright Counseling and Consulting. Emergencies: You may encounter a personal emergency that may require prompt attention. Your clinician will make reasonable efforts to respond to your emergency in a timely manner. If it is after-hours or on a weekend, or you reach the office voicemail during an emergency situation, please go to the nearest emergency room, and ask for assistance regarding a mental health emergency or call 911. Appointments: Services are by appointment only. You are responsible for keeping your appointment and timely arrival. In the event that you cannot keep an appointment, it is your responsibility to call/text your clinician at least 24 hours in advance to cancel or reschedule. No-shows or cancellations within 24 hours will be charged the regular session rate. Any type of audio/visual recording is prohibited in sessions, without prior discussion and consent. Confidentiality: You are protected by the confidentiality laws in Texas, which state that anything discussed during sessions and meetings is privileged information and cannot be shared with anyone else without your consent. This also means that we cannot tell anyone whether you are receiving services from Shine Bright Counseling and Consulting, PLLC without your permission. Possible exceptions to confidentiality include those provided by laws, including but not limited to child abuse, abuse, neglect, or exploitation of the elderly or the disabled; AIDS/HIV infection and possible transmission; criminal prosecution; child custody cases. These records are confidential pursuant to certain legal and ethical limits and clinical parameters, and the HIPAA Notice of Privacy Practices. Within these limits, the information revealed by you will be kept confidential. No information will be released without your written consent and authorization unless mandated by law. Possible legal exceptions to confidentiality include, but are not limited to, the following situations: · If you reveal information that indicates, you are a danger to yourself or someone else necessitating a duty to protect or duty to warn. · If you reveal information about child abuse, neglect, elder abuse or sexual exploitation. · If you are in therapy as the result of a court order, unless otherwise stated in the court order. · If I receive a subpoena or a court order to disclose information. · If you provide written permission or direction to release your record. If you have any questions or concerns regarding confidentiality, please discuss them with your Shine Bright counselor before signing this form. Consent to Treatment and Confidentiality: By signing this Client Information and Consent Form, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing, and I understand that I may stop such treatment or services, not under court order, at any time.
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1. NOTICE OF HIPAA PRIVACY POLICIES* This field is required.When you receive treatment from Shine Bright Counseling & Consulting, PLLC, they will obtain and/or create health information about you. Health information includes any information that relates to (1) your past, present, or future physical or mental health or condition; (2) the health care provided to you; and (3) the past, present, or future payment for your health care. The following notice tells you about their duty to protect your health information, your privacy rights, and how they may use or disclose your health information. Therapist’s Duties: The law requires Shine Bright Counseling & Consulting, PLLC to protect the privacy of your health information. This means that they will not use or let other people see your health information without your permission except in the ways they tell you in this notice. They will safeguard your health information and keep it private. This protection applies to all health information they have about you, no matter when or where you received or sought services. When you are in treatment, they will not allow any unauthorized person to interview, photograph, film, or record you without your written permission. They will not tell anyone if you sought, are receiving, or have ever received services, unless the law allows him to disclose that information. They will ask you for your written permission (authorization or consent) to use or disclose your health information. There are times when they are allowed to use or disclose your health information without your permission, as explained in this notice. If you give them your permission to use or disclose your health information, you may take it back (revoke it) at any time. If you revoke your permission, they will not be liable for using or disclosing your health information before they knew you revoked your permission. To revoke your permission, send a written statement, signed by you, to the office where you gave your permission, providing the date and purpose of the permission and saying that you want to revoke it. They are required to give you this notice of legal duties and privacy practices,and must do what thisnotice says. They can change the contents of this notice and, if they do, they will have copies of the new notice at their office. The new notice will apply to all health information they have, no matter when they got or created the information. Their employees must protect the privacy of your health information as part of their jobs. They do not let employees see your health information unless they need it as part of their jobs. They will punish employees who do not protect the privacy of your health information. They will not disclose information about you related to HIV/AIDS without your specific written permission, unless the law allows them to disclose the information. Federal law will not protect any information about a crime committed by you either at the therapist’s office or against any person who works for them or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities. Your Privacy Rights: You can look at or get a copy of your health information. There are some reasons why Shine Bright Counseling & Consulting, PLLC may not let you see or get a copy of your health information, and if they deny your request they will tell you why. You can appeal their decision in some situations. You can choose to get a summary of your health information instead of a copy. If you want a summary or a copy of your health information, you may have to pay a reasonable fee for it. You can ask them to correct information in your records if you think the information is wrong. They will not destroy or change your records, but will add the correct information to your records and make a note in your records that you have provided the information. You can get a list of when they have given health information about you to other people in the last six years. The list will not include disclosures for treatment, payment, health care operations, national security, law enforcement, or disclosures where you gave your permission. The list will not include disclosures made before April 14, 2003. There will be no charge for one list per year. You can ask them to limit some of the ways they use or share your health information. They will consider your request, but the law does not require them to agree to it. If they do agree, they will put the agreement in writing and follow it, except in case of emergency. They cannot agree to limit the uses or sharing of information that are required by law. You can ask them to contact you at a different place or in some other way. They will agree to your request as long as it is reasonable. You can get a copy of this notice any time you ask for it. Treatment, Payment, and Health Care Operations: Shine Bright Counseling & Consulting, PLLC may use or disclose your health information to provide care to you, to obtain payment for that care, or for their own health care operations. Health information about you may be exchanged between mental health contractors for purposes of treatment, payment, or health care operations, without your permission. Treatment: They can use or disclose your health information to provide, coordinate, or manage health care or related services. This includes providing care to you, consulting with another health care provider about you, and referring you to another health care provider. Unless you ask them not to, they may contact you to remind you of an appointment or to offer treatment alternatives or other health-related information that may interest you. Payment: They can use or disclose your health information to obtain payment for providing health care to you or to provide benefits to you under a health plan such as the Medicaid Program. For example, they can use your health information to bill your insurance company for health care provided to you. Health Care Operations: They can also use your health information for health care operations: Activities to improve health care, evaluating programs, and developing procedures; Case management and care coordination; Reviewing the competence, qualifications, performance of health care professionals and others; Conducting training programs and resolving internal grievances; Conducting accreditation, certification, licensing, or credentialing activities; Providing medical review, legal services, or auditing functions; and Engaging in business planning and management or general administration. They are permitted by law to use or disclose your health information without your permission for the following purposes. 1) When required by law. They may use or disclose your health information as required by state or federal law. 2) To report suspected child abuse or neglect. They may disclose your health information to a government authority if necessary to report abuse or neglect of a child. 3) To address a serious threat to health or safety. They may use or disclose your health information to medical or law enforcement personnel if you or others are in danger and the information is necessary to prevent physical harm. 4) For research. They may use or disclose your health information if a research board says it can be used for a research project, or if information identifying you is removed from the health information. Information that identifies you will be kept confidential. 5) To a government authority if the therapist thinks that you are a victim of abuse. They may disclose your health information to a person legally authorized to investigate a report that you have been abused or have been denied your rights. 6) To comply with legal requirements. They may disclose your health information to an employee or agent of a doctor or other professional who is treating you, to comply with statutory, licensing, or accreditation requirements, as long as your information is protected and is not disclosed for any other reason. 7) For purposes relating to death. If you die, they may disclose health information about you to your personal representative and to coroners or medical examiners to identify you or determine the cause of death. 8) To your legally authorized representative (LAR). They may share your health information with a person appointed by a court to represent your interests. 9) In judicial and administrative proceedings. They may disclose your health information in any criminal or civil proceeding if a court or administrative judge has issued an order or subpoena that requires them to disclose it. Some types of court or administrative proceedings where they may disclose your health information are 10) Commitment proceedings for involuntary commitment for court-ordered treatment or services. 11) Court-ordered examinations for a mental or emotional condition or disorder. 12) Proceedings regarding abuse or neglect. 13) License revocation proceedings against a doctor or other professional. 14) To the Secretary of Health and Human Services. They must disclose your health information to the United States Department of Health and Human Services when requested in order to enforce the privacy laws. COMPLAINT PROCESS: If you believe that Shine Bright Counseling & Consulting, PLLC has violated your privacy rights, you have the right to file a complaint. You may complain by contacting: You may also file a complaint with: U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201 (800) 368-1019 (toll free) You must file your complaint within 180 days of when you knew or should have known about the event that you think violated your privacy rights. You will not be retaliated against if you file a complaint. Effective Date: April 14, 2020 I acknowledge receipt of this privacy notice
ClearYour Signature
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1. Telemental Health Informed Consent: I consent to Telemental Health, if we mutually determine that it is an appropriate means to communicate. I understand that Telemental Health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in different physical locations. Shine Bright Counseling and Consisting, PLLC utilizes Doxy.Me. This internect platform is encrypted to the federal standard, PIPAA compatible and has signed a HIPAA Business Associate Agreement (BAA). The BAA means that Doxy. Me is willing to attest to HIPAA compliance and assumes responsibility for keeping the live video interaction secure and confidential. If you choose to utilize this technology, Shine Bright PLLC will give you detailed directions regarded how to log-in securely. Shine Bright Counseling and Consulting, PLLC requests that you sign onto the platform at least 5 minutes prior to your session time to ensure a prompt start time and strongly suggests that you online communicate through a computer or device that you know is safe. * This field is required.1) I understand that I have the right to withdraw consent at any time without affecting my right to further care, services or program benefits to which I would otherwise be entitled. 2) I understand that there are risks and consequences associate with Telemental Health, including but not limited to, disruption of transmission by technology failures, interruption and/or breach of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. 3) I understand that there will be not recording of any of the online session by either party. All information disclosed with sessions and written record pertaining to those session is confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law. 4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to Telemental Health unless a legal exception to confidentiality applies. 5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experience a mental health crisis that cannot be resolved remotely, it may be determined that Telemental Health service are not appropriate and a higher level of care is required. 6) I understand that during a Telemental Health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect with in ten minutes, the session will be rescheduled. 7) I understand that my counselor may need to contact to an emergency contact and or appropriate authorities in case if emergencies. I acknowledge receipt of this Telemental Health notice and agree to its terms.
ClearYour Signature
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Would you like paper copies of the policies above?
YESNO
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Today's Date
Should be Empty: