CHILD (B-9) INTAKE & CONSENT Psynamo Group Child (B-9) Intake Form 2020 Psynamo Adult Family Member Intake Form Confidentiality & Consent Confirm & Submit Psynamo Adult Family Member Intake Form Child's Full Name Age Child's Birthdate Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Gender Female Male Other Place of Birth Mother Tongue & Home Language(s) Languages Spoken Home Address Nationality(ies) Religion My child was born... Premature Less than 3 weeks early Full-Term Late My child was delivered... with no complications with minor complications with many complications with major complications My child's vision is... normal corrected with lenses squint/lazy eye impaired My child's hearing is... within normal limits corrected with hearing aides impaired My child has developmental delays in speaking walking coordination writing self-care socialising toileting Any Diagnoses, Medications, Health Issues, Therapy? Any ER Visits, Surgeries, Major Events? Any Allergies & Intolerances? Current School & Grade/Year Academic Achievement Excellent Above Average On Par Below Par Failing Past Schools) Behavioural Issues (School/Home/Social)? Extra or Advanced Support Other Activities What are your child's Interests? What are your child's Strengths? What are your child's Weaknesses/Dislikes? Recent Changes in Life? Parent/Caregiver 1 Name & Nationality Parent 1 is the child's... Mother Father Aunt Uncle Grandmother Grandfather Caregiver/Guardian Parent 1 Relation to Child Natural Step Adoptive Other Parent 1 Email Address Parent 1 Mobile Phone Number Parent's/Caregiver 1 Current Employment Parent 1 Highest Education Achieved Secondary School Undergraduate Postgraduate Specialist Qualification Parent/Caregiver 2 Name & Nationality Parent 2 is the child's... Mother Father Aunt Uncle Grandmother Grandfather Caregiver/Guardian Parent 2 Relation to Child Natural Step Adopted Other Parent 2 Mobile Phone Parent 2 Email Parent 2 Current Employment Parent 2 Highest Education Achieved Secondary Undergraduate Postgraduate Specialist Qualification Parent's Marital Status Married Co-habitating Divorced Re-married Widowed Spinster/Bachlor Time Lived in Hong Kong? Previous Locations? Others in the Home & Relationship to Child Top Three Concerns Confidentiality & Consent Check the box above to confirm you have read the following. OUR PRIVACY AND CONFIDENTIALITY POLICY Collection and Use of Personal Information: Our privacy policy reflects both our voluntary adherence to the ethics prescribed by the majority of mental and allied health professional membership-based organisations worldwide and our full compliance with all regulatory requirements. We only collect information about you to identify personal information, to obtain consent for services, to maintain records for the benefit of all parties, to inform services carried out for your support and for the legal requirements of those receiving assessment services and for tracing defaulters. Release of Personal Data: Personal data will only be released to third parties where express written consent has been specifically granted by yourself, where such disclosure is allowed under the Personal Data (Privacy) Ordinance or where we may be legally required to do so by direct court order. Data will only be disclosed to parties where express written consent has been given to such disclosure or where such disclosure is allowed under the Personal Data (Privacy) Ordinance. A fee may be imposed for complying with this data request. The provision of personal data is voluntary, however, if insufficient or incorrect information is provided, Psynamo Limited may not be able to provide the most beneficial or complete services and does not accept responsibility for results based upon such information where it is incorrect or insufficient as provided by the client. Access to Personal Data: You have the right of access and correction with respect to personal data as provided for in sections 18 and 22 and Principle 6 of Schedule 1 of the Personal Data (Privacy) Ordinance. Enquiries concerning any personal data provided, including the making of access and corrections, should be directed during office hours by telephone on +852 9676 6506, by email on admin@psynamo.com or by post to; Suite 1205/6, Car Po Commercial Building, 18-20 Lyndhurst Terrace, Central, Hong Kong. Consent for Data Collection and Retention: I confirm that the information provided here is true and accurate. I give my consent that the above information may be submitted to and kept by Psynamo Limited and to be used in the process of arranging for invoicing and regular communications as they pertain to the services for which I have agreed to engage. I understand that all information provided will be kept in strictest confidence. OUR CONSENT TO TREATMENT Receiving Psychological Services: Working with a mental health professional is a unique endeavor and represents an important relationship based on mutual respect and trust. All psychotherapeutic support and assessment services are completely confidential, non-judgmental, are held within a therapeutic framework of the practitioner, and do not represent advice, medical or otherwise, emergency support services, or any other form of practice. The content of sessions and therapeutic work may bring up uncomfortable feelings and may feel challenging at times. Treatment effectiveness varies from person to person and each therapist will utilise their preferred approach only for your benefit. Sessions/Fees: All sessions commence on the hour and appropriate fees are payable on the day of your appointment. Individual sessions are held for 50 minutes and couples/families sessions are held for 75 minutes (1.5 sessions). We require 24 hours advance notice (before 5pm on Fridays for Monday appointments) for cancellation or change of appointment for no fee to be incurred. Confidentiality of Sessions: Documentation collected during the course of psychotherapy and/or assessments forms are retained by your therapist for the benefit of case conceptualization, planning, and measuring progress towards your therapy focus. This may include background information, data released from third parties or produced as part of any assessment, as well as ongoing notes of the therapist. This data is destroyed seven (7) years post-therapeutic termination. Regular supervision and case consultation is required of all therapists but case information is always limited to pertinent details and no names are released apart in circumstances where confidentiality must be breached as a professional standard, including the case of harm to self, harm to others, or actual or suspected minor or elder abuse/neglect is revealed in session and in the case of subpoena by a judge in the Hong Kong court systems. Consent to treatment is an ongoing process and your therapist will always discuss change to agreements as they arise. We do not provide statements/representations/reports for legal/forensic purposes. Confirm & Submit Select a therapist Dr Scarlett Mattoli Christine Meaney Joe Clark Priya McPolin Lucy Lau Zaha Refaaq Confirmation of Form Submission I confirm the details I have completed on this form are correct. 9 + 1 =
