Bloom Pediatrics
Nature. Nurture. Bloom.
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Parenting consultation questionnaire

To schedule a private consultation, please fill out the form below. We can help you increase your awareness of your child’s unique needs, learn strategies for successful parenting, and expand your resources.

 

Parenting consultation questionnaire

PARENT INFORMATION
Parent #1 Name *
Parent #1 Name
Parent #1 Phone *
Parent #1 Phone
Parent #1 Address *
Parent #1 Address
Parent #2 Name (Optional)
Parent #2 Name (Optional)
Parent #2 Phone (Optional)
Parent #2 Phone (Optional)
CHILD INFORMATION
Child #1 Name *
Child #1 Name
Child #1 Date of Birth *
Child #1 Date of Birth
Child #2 Date of Birth
Child #2 Date of Birth
Child #3 Name
Child #3 Name
Child #3 Date of Birth
Child #3 Date of Birth
ADDITIONAL INFORMATION
Please answer the following questions to help us better understand your needs and optimize your consultation time.
REQUIRED FORMS - PLEASE READ CAREFULLY
Financial Responsibility and Security of Payment *
All boxes must be checked in order to schedule your consultation.
Method of Payment *
Please select preferred form of payment below. To keep the cost of services down, Venmo @bloompediatrics or check are preferred forms of payment. Credit card information is required for registration fee and security of payment.
Name on Card *
Name on Card
$125 per 30-minute consultation or $205 per 50-minute consultation.
$
Payment Authorization *
HIPAA Notice of Privacy Policies *
In compliance with the Health Insurance Portability and Accountability Act’s Privacy Rule (HIPAA), your child’s private health information (PHI) will be protected in his/her medical records, in consultation with other professionals involved in your child’s care and with payers, HIPAA requires that your child’s PHI be kept private and that you are notified of the privacy practices with respect to your child’s PHI. A summary of the policies follows. MEDICAL INFORMATION Your child’s PHI may consist of evaluations, diagnosis, daily notes, progress notes, Individual
Family Service Plan (IFSP) Individualized Educational Plan (IEP), insurance information, physician prescriptions, and correspondences to your other medical and educational providers (e.g., physician, therapists, service coordinators, psychologists, social worker, school personnel, etc.) COLLECTION, STORAGE, DISCLOSURE AND DISPOSAL OF MEDICAL INFORMATION • Your child’s records will be kept in a file with his/her name on it. These files are stored in a locked container in your therapist’s home office or in a central file at our office. Your child’s records may also be stored in a computer only accessible to your child’s therapist(s). • Correspondence with others regarding your child’s PHI will only include other members or your current child’s healthcare provider team to discuss your child’s course of treatment. 
 • At your request, correspondence with outside consultants or educational personnel will be made. Your written consent is required for this communication to take place. • All phone correspondence with other members of your child’s healthcare team or payer will be conducted on a private phone line in a confidential manner, so others cannot hear the conversation. • All faxed information about your child will include a fax coversheet with a confidentiality statement. No confidential information about your child will be included on the fax cover sheet. • Correspondence by mail will be addressed to specific individuals for the purpose outlined above. • A written record of all disclosures of your child’s PHI will be kept. • Only the Minimum Necessary Requirements will be disclosed to the entity requesting information. This means that only the minimum amount of information necessary to complete the task for which the entity is requesting the information will be provided, rather than sending the entire le. • Your child’s therapist is your child’s Privacy Officer. Each therapist is responsible for protecting your child’s PHI and following these guidelines. • Your child’s records will be kept and stored for a minimum of 6 years. After this time, the records will be shredded to protect privacy. YOUR RIGHTS UNDER HIPAA • You have the right to inspect and copy your child’s personal health information. The request must be made in writing. • Your child’s PHI will be used strictly for evaluation and treatment planning. • You have the right to request information about who PHI has been released to. • You have the right to take away permission to disclose information to any party at any time. This request must be made in writing. • You have the right to complain if you believe your privacy rights have been violated. if you feel your rights have been violated, please contact us. You may also file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights at hhs.gov/ocr/privacy/hipaa/complaints/, 877.696.6775, or U.S. Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, SW; Washington, D.C., 20201. We will not retaliate against you for filing. SUMMARY OF RESPONSIBILITIES We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We will give you a hard copy of this notice and follow the duties and privacy practices described in this notice. We will not use or share your information other than as described here unless you tell us in writing that we can. You may also change your mind at any time and let us know in writing if you do. Additional information is available at hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html TERMS OF CHANGE We can change the terms of this notice. Any changes to this notice will be available to you upon request, on our website, or office. These changes will apply to your information we have on file.
Electronic Signature Agreement *
Today's Date *
Today's Date