Foster Care Intake Form

Child General Information

Child's Name*

First Last

Child's Nickname, If Applicable*

Gender*

Male
Female

Child's Social Security Number (Last 4 Digits)

Child's Date of Birth

Child's Age

Foster Parent's General Information

Foster Parent's Name

First Last

Foster Parent's Phone*

Foster Parent's Email*

Foster Parent's Address*

Street Address Address Line 2 City State ZIP Code

Court Paperwork Information

DCBS Worker's Name

First Last

DCBS Worker's Phone

DCBS Worker's Email

I agree to provide a copy of court / custody paperwork

Bring to appointment.

Yes

Child Trauma / Placement History

Please share the main reason/behavioral concerns for seeking counseling:

Has the child had therapy previously?

Yes. No. How long?

When was the child removed from the biological family’s care?

Why was the child removed from care?

Is this the child’s first foster placement?

Yes
No

If not first placement, please describe previous placements and length of time:

Is the child having difficulty finding pleasure in leisure activities lately?

Yes
No

Has the child’s appetite changed recently?

Eating More
Eating Less
No Change

Has the child’s sleep changed recently?

Sleeping More
Sleeping Less
No Change

Is the child experiencing nightmares?

Yes
No

Does the child have sexualized behaviors?

Yes
No

Does the child experience bed wetting?

Yes
No

Does the child have a history of sexual abuse?

Yes
No

Does the child have a history of neglect?

Yes
No

Does the child have a history of psychological abuse?

Yes
No

Child Health History

Has the child been seen by a medical doctor in the past year?

Yes
No

Child's Current Pediatrician

First Last

Pediatrician's Office

Would you like us to communicate and collaborate with the pediatrician?

Yes
No

Has the child seen a dentist in the past 6 months?

Yes
No

Please list any current medications and suppliments the child is currently taking:

Medication, Dosage, Prescribed By

Does the child have any chronic illnesses?

Example: Asthma, diabetes, heart disease, etc

Does the child have any allergies?

Did the birth mother use drugs or alcohol while pregnant with this child?

Yes
No

Any issues with pregnancy or delivery?

Yes
No

Did the child have any developmental delays? Walking, talking?

Yes
No

Any sensory issues? Sensitive to touch, loud noises, smells, bright lights:

Are there any mental health issues that run in the child’s biological family, such as depression, anxiety, ADHD, schizophrenia, etc?

Is there any history of substance abuse in the family? Explain.

Consent and Permission for Treatment

I understand that Willow Creek Counseling Center, LLC is providing mental health assessment and treatment services to my child and family. I understand that there are no certain outcomes from these services and that individual experience with treatment may vary. In giving consent to Willow Creek Counseling Center, LLC to provide these services to me, I am aware that Willow Creek Counseling Center, LLC has a duty to protect my confidentiality except where the law requires disclosure of certain information. There are several situations in which Willow Creek Counseling Center, LLC cannot assure confidentiality including:

Willow Creek Counseling Center, LLC has a duty to report the abuse or neglect of a dependent adult and/or domestic violence offenses to the Department for Community Based Services;

Willow Creek Counseling Center, LLC has a duty to report any instance of child neglect, exploitation, or abuse to the Department for Community Based Services and/or the police;

Willow Creek Counseling Center, LLC has a duty to report any threats against persons to the intended victim and to the police;

Willow Creek Counseling Center, LLC has a duty to release information to agencies or persons with a need to know when a client is in need of hospitalization; and

When a client introduces personal mental health or substance abuse issues in court proceedings then confidentiality is waived by the client.

Understanding all of the above possible waivers of confidentiality regarding information about my mental health and/or substance abuse condition and treatment, I give consent to Willow Creek Counseling Center, LLC and its therapists to provide assessment and treatment services to me.

Federal Rules prohibit any party from making further disclosure of this information “unless further disclosure is expressly permitted by the written consent of the person to whom it pertains” or is otherwise permitted by 42 CFR part 2.

I will receive a copy of the Notice of Privacy Practices. I will be allowed to ask any questions about this pamphlet and they have been answered for me.

I understand that Willow Creek Counseling Center, LLC and their therapists do not and will not express opinions for custody and/or visitation at any time. The therapists’ role is to strictly provide therapy and they do not participate in reunification. I agree not to subpoena any staff members for court proceedings to testify for custody and/or visitation hearings.

Clinicians for this client will explain this form to the guardian and foster parent and answer his/her questions.

I have read the above and agree*

Yes

Appointment Reminders

Willow Creek Counseling Center, LLC can remind you of scheduled appointments the day before your appointment. This is offered as a service to you only with your permission, you may opt out of this service by selecting the appropriately below.

Preferred Appointment Reminder Contact Method:

Phone To Text

Phone To Call

Reminder Email Address

Financial Responsibility Statement

Insurance/MCO:

Insurance ID#:

Medicaid ID#:

DCBS Responsibility

I agree that DCBS is fiscally responsible for services rendered by Willow Creek Counseling Center. I give permission to Willow Creek Counseling Center, LLC to submit a claim to the child’s insurance.

Yes

Authorization to Disclose Health Information to Foster Parents

I authorize the use or disclosure of the above named individual’s health information as described below for use by Willow Creek Counseling Center, LLC to assist in the diagnosis and treatment of the named individual and/or the individual’s family. I also authorize Willow Creek Counseling Center, LLC to communicate relevant information obtained over the course of treatment.

The type and amount of information to be used or disclosed is as follows:

All diagnostic and assessment information including psychological or psychiatric reports and evaluations

Other: verbal and written collaboration

I understand that the information in the child’s health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to Willow Creek Counseling Center. I understand the revocation will not apply to information that has already been released in response to this authorization.

I understand that information used or disclosed pursuant to the authorization may be subject to disclosure by the recipient of my information and no longer protected by the HIPAA Privacy Rule.

I understand that information used or disclosed pursuant to the authorization may be subject to disclosure by the recipient of my information and no longer protected by the HIPAA Privacy Rule.

Agree To Disclose to Foster Parents

I have read the above agreement.

Yes

Authorization to Disclose Health Information to School

I authorize the use or disclosure of the above named individual’s health information as described below for use by Willow Creek Counseling Center, LLC to assist in the diagnosis and treatment of the named individual and/or the individual’s family. I also authorize Willow Creek Counseling Center, LLC to communicate relevant information obtained over the course of treatment to the individual, entity, and/or facility listed below.

The type and amount of information to be used or disclosed is as follows:
- All school records
- All special education records such as IEP or 504 plan
- All diagnostic and assessment information including psychological or psychiatric reports and evaluations
- Other: verbal and written collaboration

I understand that the information in the child’s health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to Willow Creek Counseling Center, LLC. I understand the revocation will not apply to information that has already been released in response to this authorization.

I understand that information used or disclosed pursuant to the authorization may be subject to disclosure by the recipient of my information and no longer protected by the HIPAA Privacy Rule.

School System

School's Address

Street Address Address Line 2 City State ZIP Code

School's Phone Number

Disclose to Foster Child's School

Yes

I have read the above agreement.

Signature

I have read the above agreement and authorize treatment, payment and all disclosures included in this form.

DCBS Worker or Guardian's Name

First Last

DCBS Worker or Guardian's Signature

Child General Information

Foster Parent's General Information

Court Paperwork Information

Child Trauma / Placement History

Child Health History

Consent and Permission for Treatment

Appointment Reminders

Financial Responsibility Statement

Authorization to Disclose Health Information to Foster Parents

Authorization to Disclose Health Information to School

Signature

Address

Client Portal

Address

Client Portal

Phone

Email

Phone

Email