1. health and fitness

Harvey Shubert, Ph.D.
-
4115 East Valley Auto Drive, Suite 208
Mesa, AZ 85206
480-507-7880 Fax 480-507-8103
.
PARENT QUESTIONNHRE
In order to best be able to help you and your child, we need to know some things about your family.
Please answer each question as completely as you can and explain any.Jres,, or.ho,, answers.
Background Information:
Client's
name:
Biological Parents'
Date of Birth:
Name:
Sibling Names
Age
Education
Occupation
Age
Education
0ccupation
List any other living in the home:
Dates of marriage and/or divorce of biological parents:
Ifthe client's biological parents
Name of
Parent
are divorced, please
Date(s) of
filt
in the following information:
Name of Second Spouse
Marriage
Custody and visitation arrangemenrs:
Ilistory of Problem:
What is the problem? Why are you bringing in your child for an evaluation?
When and how did you first notice the problem?
What kinds of changes have you seen in your child which seems to be a part of the problem?
How have you tried to resolve the problem?
Please describe any major incidents, such as moving or the death of a family member, which
seems to have affected
your child. What was his/her reaction?
What other major changes have happened in the family (additions, losses, financial changes"
moves, etc.?
Family Interaction:
Describe your relationship(s) with the client's sibling(s):
What do you do together as a family?
How are decisions made in your family?
Please describe early eating and sleeping patterns:
as an infant?
as a toddler?
as a preschooler?
childhood or Iater years?
Haveyou noticed any unusual eating patterns (such as fasting, constant dieting, eating a lot at one
time followed by not eating, etc.) or changes in the client's eating habits? Ifyis, pleaie describe:
Educational History:
What school is the client enrolled in?
Grade?
How old was the client when helshe started school?
Has the client repeated or skipped any grades? yes
No
Have there been any academic, behavioral, or emotional problems with peers or teachers? Ifyes,
when did the problems begin? What were they?
What kinds ofgrades does the client usrally get? Describe any recent changes?
Has the client ever been assessed for learning probtems (LD/EBD) or been in special classes
(chapter I or tutoring)? Ifyes, please describe:
Has the client ever been suspended or expelled from school?
happened and how you handled it:
Ifyes, please describe why this
Treatment History:
Has the client ever been taken to a mental health or chemical dependence professional before?
If yes, please fill in the following information:
Name of
Professional
Dates of
Service
Reason for Services
Please describe the history of your immediate family, including dates of births, marriages,
divorces, major illnesses, moves, etc.:
Developmental History:
Was the client a planned chitd? How did parent(s) react to the pregnancy?
Were there any complications during the pregnancy and/or birth of the client?
describe?
If
yes, please
Please describe the client's emotional and behavioral adjustment (response, activity Ievel):
as an infant:
as a toddler:
as a preschooler:
during grade school:
during j unior high:
during high school:
At what age did the client:
say a single
word? _
crawl?
bowel trained?
simple sentences?
walk?
interested in other children?
Were there any problems with toilet training?
If
complete sentences?
bladder trained?
yes, please describe:
Were there any problems with wetting or soiling the bed after the client had been toilet trained?
yes, please describe:
If
How well did the client tolerate normal separations before school age?
Please describe early eating and sleeping patterns:
as an infant?
toddler?
as a preschooler?
childhood or later years?
as a
Have^you noticed any unusual eating patterns. (such
as fasting, constant dieting, eating a lot at one
time followed by not eating, etc.) or ciranges i, tt
ctientls
habits? rr#., pr""'." a"r".iu",
"
"iiing
Educational History:
What school is the client enrolled in?
How old was the client when helshe startid schonlZ
Has the client repeated or skipped any grades?
Grade?
y-
or emotional problems
:il:1T:,1"1:iI_T?tT:,.*havioral,
when did the problems begin? What were they?
with peers or teachers? rf yes,
What kinds ofgrades does the client uqually get? Describe
any recent changes?
Has the client ever been assessed_ for learning problems (LD,EBD)
or been in speciar classes
(chapter I or tutoring)? Ifyes, please describe:
ever been suspenaea o
I"lr-,1_"
nappeneo and how vou handled it:
:':ll
Treatment History:
Has the client ever been taken to a mental health or chemical
dependence professional before?
lf yes, please fill in the following information:
Name of
Professional
Dates of
Service
Reason for Services
Has the client ever seen a school counselor or school psychologist?
including the reason(s) and dates(s):
Ifyes, please explain,
Has the client ever been placed out ofthe home for mental health, emotional and/or behavioral
reasons (foster care, impatient treatment, residential keatment, juvenile detention, with relative,
etc.): Ifyes, please explain:
Has anyone else in the family received psychiatric, psychological and/or chemical dependence
treatment in an inpatient or outpatient setting? Ifyes, please explain:
How do you feel about seeking help for your child at this time?
What goal(s) do you have for the treatment of your child?
What educational material(s) have you read related to the problem area(s) for your child?
Miscellaneous:
What else do you need to know that we haven't asked you?
HarveY Shubert, Ph.D'
4115 E. ValleY Auto Drive, Suite 208
Mesa, AZ 85206
Phone: 480-507-7880
Fax: 480-507-8013
ACKNOWLEDGMENT OF RX,CEITT OT NOTICE OT TRIVACY PRACTICES
acknowledge rhat I have received a copy of
Harvey Shubert, Ph.D. Notice of Privacy Practices. This notice describes how Harvey shubert,
Ph.D. may use and disclose my protected health information, certain restdctions on the use of
my healthcare information, and rights I may have regarding my protected health information.
Signatr:re of patient or pe$onal representative
Relationship to patieat
Date
Harvey Shubert, Ph.D'
NQTICE OT PP.ryACY PRACTICSS
TI{ISNoTIcEDEscE.aEs}TowPRoTECItrDIISALTHINFo!.\'ATIoNAsourYoul\[4'YBE
UsxDANDDIscLosrDANDHowYoUc.drvGBTACCEssToTtIIsIMoRlvlATIoN.
PLF.{SE REVMW TT CARTF'LiLLY
This norice tells you about the ways ir which Harvey Shubcrt, Ph.D. may collcct, use, and disclose your
prctected health informatioD and your rights conceming your plotected health infonnatin. "Protected Health
informatio.,' is info.mation about you, including demographic iofonnation, that can reasolably be used to
provision
identiry you and that relates to your past, present, or f,lture physical or mental health or conditiofl, tlle
ofhealth care to you or the payment for that care.
about your dghls and oul legalduties-and
We ar€ rcquir€d by Fedsral ald Sirte laws to Fovide yo! with rhis l';o$te
follow tbe terms oftlis Notice while it
Wc
ntust
n;vacv Diadices wittl resp€ct to }our protected he'alltr'tutorEal;oo
iimired in certai! cases br alplicable
be
may
this
Noticc
in
d,""i""*.s <rescribcd
: ;';#"?:";;;r";-;;;;
pfivacy'Rule for the fiIst lille cfeates
HIPAA
The
fed€ral
standalds.
than
&e
i* i"*rir,* ,* *oru eriagent
prot€rt;dividuais' medical resords aud other personal health iaforma{on'
;;;; ;;;;
purposes- The exa$trles below a.re
We may use al}d rlisclose .vour protecred health iqto.tnation for dif'ere*
yolr au:horizatioo for pa)'trrei$' hea'l&
lvitbout
pr""f& t if l*o*" tn" typu, of usu, *a disclosltr:es we may mai(e
care operadons and teatnentto your &sltraace 6ompa'y in older to tcceive
PAYIvfENI: lve usc aqd disclcse your lrotepied lr{atb infoffsation
palmofi for your covered beal& expemes'
healh care providers
to otbct
HIALTH CARI,I We rnay use and disclosc your groected healttr iE omation in your dbgDosis
laboraiories, orhospitals) to batler assi$t
ffi"ir -n;,!"*rfrofesuionals,
aod trea&rent
will disclose your prot'rted healtb lafonaalion if ws receive a request Ao0'
your
wili
be tlexing yotl wi& a signed request &o{r you^,. wt will disclose
or
;ffi6ttd*
your
protected
will
We
disclose
pr"*"JiJA irf"r-"ion to ino&er physician r1w1!A:io11o that physiciaa.
ou.your behall We x'ill diselose yout protected
heahh iufornution to an insurance co.,pant itwe have liled a claio
iIEDICAI'&ECQ&D$BEO!&ST:
S!
-h" tt k""tl"g y*
i""i
u r,"r""r*1"",
*irl
,""tiog tif" o.l"rirh
yo,r.
*rlo;*o*,
you are
to a life iosurdace uoderwrircr or heal& ir,surance compaay if
comfruy !o comct us for your mcCical history'
ia.surance coverage and have requested a
patieEt's Protected health io$rmation lbr rurketing purposes' a
autbqrization to usE this parisat's itrJomlation wil1 be *quked- Daniel J. Christiano, Ph.D.
"irf"r,
o"vei s"il ii$s of patiest's name;idotmarioo to ao) third parry'
MARKETING: Ifoul ofrce ever decids to use
Iti"otkffi
*ill
a
.,
orri{ER PERMIIIED
O&.*ljAUlREp-a$!La$a!!
aboul you when reqdtcd to do so t'y law'
As Re{ruileil by Law: We slusl disclose prote$ed healrh infonnatioD
&Ig!E &!di!g!S.
S1ate
law gov&ms distlosures to pareDts'
legaiiy-ar€ adulB: Without prior author?-a:io& xe
Patients l8-2?, wLo are financially dependeot on rieir pareols, )et
(a,d ir so*e cases, \{e calno! disclosa a
un uaob patient health status !o aEyoDe including par.-'nts
kolii*tii
minor's individual heald dala).
of l3 llu51 t'c accompa'ded by a pareat or lsgal
Chjldrsn urder 18: Ir is our offce poliry that any cbild uoder the ag*
an au&odzztior for trca&mnt of
visit to our oscel The pircat or represeotarive may then sign
ffiffi;';;;;*t
the child whe, theY &Ie 001\tith thell.
Genelal publicleal&flqtivities- qre may disclose protected tr 1& informarroa to public hsaitb agenci$
for
as preyedilg or conhollitg diseasE, isju-./, or disabiiily.
reasoff suci
Victii4i of Abuse. Neslecl or Domeslic Violence. We may disclose prokcted health information
agencies about abxe, neglect or domestic r,ioleace,
to goi,emnea1
Health Ovsnigbt Acfivities" We roq/ discloso protected healrh infxmation to government oversight agencies (e.g.,
state itrsurauce depame s) for activirix authorized by larvJudicial aad Administ'ative &ocacdinBs. We may disclose pmtected hoalth iqfom.arioo in respolse lo a qourt o.
adminisFative order. We ma,v also disclose prol€cted hcahh informalion about you irt certain cases in response to a
Subpoel4 discOVery reqrcst or other la\4d{ process , and alisclose rccords to legal counsel for the purpose of seeking legal advice.
I.aw Enforcemenr. We may disclose ptotected healdr informafion q!de! limited circ,rpq.rces to a lar,v enforceqena
in respe$e ro a warmnt or simikr process; ta ideatiry or tocale a suspecx; or ro providr inlormatiol about tlre
victirn of a 6rime.
o$cial
Corcfiers. Fuleral Dircctors- OrgaE Donatiops. We may releas€ proiected health inlomarioa to coroners or funeral
dire4ors as necessary to allow them to carry out thcir duties. Sy'e say also disclose protected health irforma:ion iI
cooaectiou wittr organ or tissue donatioB.
Researc\, Uader cefiait circr[lstaoces, we rEay disctose p$tecred health iDfonuafoq about ]gu for reseatch
purposes, provided cortai8 Eeasurcs have been tal(e[ to Fotect your privacyTo Aven a Serious Threar ro l{paltor Safeqf. We may discir)se proiected bealth ir:forraation about you, with some
limitaions, wher necessary to preleat a serious threat io your hea.l& and sa{ery or rhe hedrh aad xfety of&e publc
or another penor.
SDecial Govemment Flmrtiors' We may disclosc plotccted healtb informatio!. about yqq with soee limitatioas,
when Betissary to prevclt a serious ihreat to your health and safety or the heal& ard safery ofthe public or aao&er
pcrso!-
SDocial Gov€rr1{1e t Fuqqligr5 We lnay disclose protEcled beal$ inlo.marioa
to au&orizcd federdl ottrcials ior national securiB aad inteuigence activities_
as requi.red by
oiliraty authoritieg or
$/orkers' Codrpq!&liop- We may disclose protected hea}h hfo.oatioq to &e cxtertt oecessary to comply wi&
state Lw for
wo*en' compemation progmms.
of uEE_u!E;-Q&.
DISCLOSnRES WrTll Ai\* Ar jTHORrZATrol_{
Otler
uses o: disclosures ofyour proteated healtir informatioa will be maiie only with your wdttetr althori.zatirls,
udess otherwise ptrmitted or required by law. You may reeoke an au&orization at any lime in writing effective
with the date ofthe leucr ofrelrcarior.
YOUR fuGIlTS RECAITDINC YOUR PROTECTED TIEALTFI INT'OEI,IATIO}i
You have certain righls regarding protected Lealrh iolorynation rhat our otfice maintains about 1,o!R-[GI{T To ACcEss YouR PRaTTECTED Ifi.ALT}l nlEaBMAIio!{. you have rbc right ro rcvievr' or obtair
copies ofyour protected health iaformation records, Your requesr to teview and/ot obtai[ a cop] olyour p.otected
beaki Morrsation records Iansr be made in .,Titing^ we may charge a feB for d1e costs of prouuchg, copyiag"
maiLing yorlr requesred inioraatior, but r*e 1'ill tell you &c cost itr adyaBce"
RIGHT TO A}{ENI| YOUB" p&OIEqTED HI{t'm \TO&MATTON tf you fcet rhat rbe protected healrh
i&formafiol Bairrtaioed by our office is incon'ect or hcoroplete, you may requesr tlat we zanead tbe idormationOur lequest mnst be made iD wrirtlg alrd mu$t iqclude tbe rgason you are seeking a chaDge. We ,oay d€ay yorE
request, for exaq,le, you msy ask us lo amend something il yorlr record &ar B,as no1 crc-aled by ol]r o6ce, as is
often lhe case *'hea &e lnformalion oay come to us toe another physician" bealth care prolbssional laboratory, or
hospital. We may deny your requesa ilyou ask us to a$eod a record that is &k€ady acc'urate
arxd
complete.
deay your request to amead, we will noti$, you ir x,ri!aS- You ftel] hava tie rigbt lo subEil io us a \+"inetr
stateroert of disageement viith our decisior aad we have &e righl lo rebut that slatemeat.
Ifwe
ruGHT TO AN AC{OUNIINC Of DISCLOS{..IRES BY T!{E PLAN. You hate the right to rcqucst aa accouati:og
ofdixlosures sc have made oiyour prolected bealth iaformatior- Your request for an accounting ofdisclosurcs
mr1st b€ Bade in *r'iaiag atrd must state a time perlod for which yoll want an accouBting- This time period may not
be longer tlan six years, aad may not hclude dales before Sep&Bber 2 , ?009. Your request should hdicare in
'what form you yatrt &e list (ex&ple: or paper or electonically)- The first accounting lhax you request wi&fu a 12month period will be Aee. for additioual lists, *'e raserve the righl to charge br &e cost ofprovidirg the lisr
1
EJGII_TO sEOi&$[_BgSIgeg9]Ls_oJ.I.f].lE usE AN] r]IScto*slJRE c'r_.YauL JB.o].EercDl€Ar.&
NrORIVfATION- You have the rigbt to req[est thaa,rre rcsEica or lilrit hola we uJe or disclose yor.r protected
hea]th information for uta&ea! pa).rmetr! or health care operations- We Inay not agrce to yol]r rcqlesL lfwe do
4greq :re ,*i11 cooply witb your requcst ualess &e infornation is needed for an emergeucy- Your reqrest for a
resaictior must be trIade itr flIiting. l! your requesE reU us (1) what infomatior you waa, ro liairi (2) whette. you
rhDt ae lim;t how we nse or disclose your intormatio!,, or bo&; ad (3) to whom )ou q'ani the reshictions to apply.
&Icfff
Tq BE];EI/E-CoNL,IDE:|rII'IAL COI{MuI{ICATIoNS. You have the right to rcquest thai we rl.se a
certain method to communicate r,virh you ifthe colalnudcalioB could euda.oger yor:- Yow requcst to recaive
conide*ial commrmicatioos must be mad6 in rxitfug Your request mnst clearty state {hai all or palt ofths
com&ueicaliotr toB us could endaager you. 1Ve will accommodate al1 reasonable requests. Your request musi
specify how or where you wi-sh to be contacted
EA&AqA3MAII_AW
You Eay exercise ally of the rights
described above by contactiry Dar BeEal. See the end ofthis Notice for ths contlct itrforBalioo-
HEALTH INFORMATiON JEEU&ITY
Ilarvey Shubert, Ph.D. requires its employees and associates to follou,the the office security policy and
procedures that limit access to health information about patients to those employees and associates who need it to
pefonn theirjob responsibilities. ln addition, Han ey Shubcft, Ph.D. maintains admidstative, and technical
security measures to safeguard your protected health informatioa.
EHANCEI.TOJffSS EOLIEY
Harvey Shubert, Ph.D. rcscrvcs the right to change the tcnns ofthe Notice at any tine, effoctive for protected health
infomlation that we already have about you as well as any infonnation that we receive in the future. We will provide you
with a copy ofthe new Noticc whcncver wo make a material change to thc privacy practiccs descdbcd itr the Noticc.
eOl\4}LA]}!IS
believe tiat your privacy rights bave beetr violar€4 you roay file a cortrplairt *ilb us ard./or with the S€cretary
of the Depa.fiae1'tt of I{eal& and Hrrlnal] Seryices. All complairts must be made ir writing and s€nt to the Omce
listed at the end ofthis 1,{ctice. We support your right to protrca &e privacy of}'our prolected healtb iriormadoL
We will not retaliate againsr you or penalize you for filing a comglaht.
lfyou
RIG-HT TO R"EVOKE HEALI'I{ CARE
ALTHqRIZAJ'}O5
You have tJre right to revoke the I,EAL?H CARE AUrHoRIzATIol,,l FoR.vt. in wriring,
at aay dme. However,
your,written request to revoke your AUTH0RIZATIoN is not efectiye to rie extert tLa;;
ha;e troia"a ,rrri"",
'
or taken actior in reliance on our authorization. you may revoke your AUTHORIZATION q,
*uiii"g
delivering a wriuen notice to our ofiioe at the address lis,ed at the end of&e Nqtice. The revocarion iinot
e$estive
until it is received try our office"
;h;d
The
r+T
'
.
.
.
itten notice must contain the following information:
Your namq Social Security )iumber and date ofbi*h
A clear statemena ofyour int€ to revoke your AUTHORIZATION,
The date ofyour request, and
Your signature.
The AUTHORIZATION is requested by flarvey Shubert, Ph.D. for its own usc/disclosure ofyour protected health care
information. (Minimumneccssary standards apply-)
You have the right to refuse to sign this AUTHOzuZATION. If you refuse to sign this AUTHORIZATION, Harvey
Shubert, Ph.D. reserves the right to refuse se.vice. A copy ofthe signed AUTHORIZATION will be provided to you at your
request.
MISSED APPONT!4ENTS Unlike semc other mediral pr pqramedical profcssionals wlro operate on mors
flexible and iaexact schedules, ynur counselor comrnits a spe.ific time peliod, usually 45-55 minute sessions. to
€ach F8tient It is important that you appreciate th6 f&ct that this block oftime has been s€t aside ior yor. Oxr
schedules arc usuall]" cro\t'ded. Your canceling or rsscheduling your appointrient $ithout sufficienr flotice ofL.
means ihe loss of ar hour oit}lei?py, and i1 is dillicult to reassign the hcu. to someo're .;se orl short notice, A
charge may be made for acy appointrneol not canceled 24-hours in adyance-
f.AlffijgJO!&EtLL
We accept insurance payrr?ents but you arc rcsponsible lor aay balance or the account, Cash
acrounts or insurance co-payments a.re due at the time ofservice, If \ye are to submit for reimbursement for your
insuraocG carrier. it i: your responsibility to provide us wirh tbe proper forms and necessary signatures. New clairn
forms may be acedod at the bcginnirg oleach calendar year.
OIFrCE HOURS Susiltess hours a.re 8:00 a(n ro 12 door and 2:00 to 5:00 pm, Monday through Friday. Ifyou
telephnne tbe ofiice at othcr than those {imis iisted or *hen the therapist is in session or out ofthe office, an
answerirg machine will record your message srld we will rcturn your call os quickly as possible- You may also use
the an:wering machine to adyise us ifrou need to calcel an appointnent. Our afier hourUrgent C{re number is
2i houi arisi: line al (602)212-9{4{. Should you h.ye
thrl you call9lI or the 24 hours crisis liae.
the Mericrpa Crisis Ceater
emergency, rv. suggest
&
life-fhrera.ring
CONTACTING IIARVEY SHURERT. PH.D. lfyouhaveanyquestionsorcomplainrsaboutthisNoticeoryou$anrtosubmita
'$Tilten request to our office in any ofthe previous sections ofthe Notice, please cail (480) 507-7880 or wrile to us at:
I
lan'ey Shubert, PH.D.
4115 E. Valley Auao Dr., Suits ?0e
Mesa, AZ 85206
Phone; 480-J07-7880, Fax: 480-50?-80 l3
Day numbcr and message number 24 hours a day (a80) 507-7880