Child / Adolescent Application Form Step 1 of 9

After speaking with our intake coordinator (212-838-4333 ext. 137), please provide us with the following information.

Answers are not saved until you click the final “Submit” button at the bottom of the page. Until that point, you can review and change any answers as needed.

Children and adolescents below 18 years of age should complete the Child and Adolescent Application.

If applying for services for someone 18 or older, please use Adult Form

CHILD’S FIRST NAME *

CHILD'S LAST NAME *

NICKNAME

HOME ADDRESS *

APT *

CITY *

STATE *

ZIP CODE *

HOME PHONE *

Child's Email

Parent's Email *

GENDER *

SEX ASSIGNED AT BIRTH *

DATE OF BIRTH

PLACE OF BIRTH

SCHOOL

GRADE

MOTHER’S NAME

BIRTHPLACE

MOBILE PHONE# *

FATHER’S NAME

BIRTHPLACE

MOBILE PHONE#

DIFFICULTIES YOUR CHILD PRESENTS NOW

DOES YOUR CHILD HAVE ANY SERIOUS PHYSICAL PROBLEMS ?

If Yes, please explain

HOW DID YOU HEAR ABOUT KAREN HORNEY CLINIC ?

REFERRED BY

LIST PREVIOUS THERAPY: (Therapists, clinics, hospitalizations, dates and length of treatment.)

LIST PRESENT THERAPY: (Therapists, clinics, agencies with whom you have an application at present and dates and length of treatment.)

REMARKS: (Please state how you feel we might be of help, and any additional information you may wish to give.)

ALL PERSONS LIVING AT HOME (Including children) For each, specify name, gender,birth date, birth place and relationship.

CHILDREN LIVING OUTSIDE THE HOUSE: For each, specify name, gender,birth date, birth place and relationship

PARENTS' EDUCATION: (Enter last grade completed.)

MOTHER

Grammar School
High School
College
Other

FATHER

Grammar School
High School
College
Other

DATES

EMPLOYMENT STATUS

MOTHER

Employed
Unemployed

OCCUPATION

HOW LONG?

EMPLOYER

ADDRESS

FATHER

Employed
Unemployed

OCCUPATION

HOW LONG?

EMPLOYER

ADDRESS

MEDICAL COVERAGE: (Insurance, Medicaid, Medicare, Crime Victims Board, Workers Compensation, Other.)

PATIENT PHYSICAL HEALTH RECORD (To be completed by parent / guardian)

1) Has your child ever been ill to the point that special medical attention has been required?

If Yes, please explain

2) Has your child ever been hospitalized?

If Yes, please indicate: (Including name of the hospital, reason and dates.)

3) Has your child ever required surgery?

If Yes, please indicate: (Including name of the hospital, reason and dates.)

4) Has your child received medicine of any type?

If Yes, please indicate: (Including doctor's name, medicine, reason and dates.)

5) Does your child have any heredity, congenital or chronic health abnormality? *

If Yes, please explain

6) Has child or mother had any of the following at birth: (Please check one for each condition.)

BLUE BABY

YELLOW JAUNDICE

BLEEDING (Abnormal maternal bleeding)

TROUBLE BREATHING

PROLONGED LABOR

FORCEPS DELIVERY

ANESTHESIA FOR DELIVERY

RH PROBLEMS

BIRTH ABNORMALITY

If Yes, please explain

Any time after the first fourteen days of life, did your child have the following: (Please Check One.)

SEIZURES

MENINGITIS

HOSPITILIZATION

EYE TROUBLE

SURGERY

DIABETES

HYPERTENSION

HEART DISEASE

LIVER DISEASE

GALLBLADDER DISEASE

STOMACH DISEASE

INTESTINAL PROBLEMS

ASTHMA

COLITIS

INJURE EASILY

JOINT PROBLEMS

GROWTH PROBLEMS

ALLERGIES

ABNORMAL MOVEMENTS

INFECTIONS :

POLIO

MUMPS

MEASLES

CHICKEN POX

RHEUMATIC FEVER

SCARLET FEVER

HERPES

DIPTHERIA

PERTUSSIS

STREP THROAT

GERMAN MEASLES

7) Do you have a regular pediatrician?

NAME

PHONE

ADDRESS

8) Vaccination Records:

POLIO

DPT

MEASLES

T.B.TEST

Positive
Negative

Date of last TB test

MUMPS

SMALLPOX

9) Has your child traveled abroad within the last 18 months?

If Yes, please specify: (When and Where)

10) Has your child received routine dental care?

11) Has anyone in the family ever had the following?

T.B. (TUBERCULOSIS)

DIABETES

HIGH BLOOD PRESSURE

BIRTH DEFECTS

LEARNING DISABILITY

BRAIN DISORDERS

CANCER

HEART DISEASE

If Yes, please explain

MONTHLY BUDGET

If you will not be using insurance, please complete the below Monthly Budget Information:

I hereby assign the insurance benefits to which I may be entitled to the Karen Horney Clinic, Inc. and I authorize payment of these to be made directly to said clinic. I authorize the Karen Horney Clinic, Inc. to communicate any pertinent data to my insurance company regarding this assignment. I also understand that if for any reason my insurance does not cover my expenses that I will be held responsible for prompt payment of any monies due:

FAMILY INFORMATION

APPLICANT'S NET MONTHLY INCOME $

APPLICANT'S OTHER MONTHLY INCOME (e.g, Social security, alimony, pension) $

SPOUSE'S NAME

SPOUSE'S NET MONTHLY INCOME $

Spouse’s Other Monthly Income (e.g, Social security, alimony, pension) $

TOTAL MONTHLY INCOME: $

MONTHLY HOUSEHOLD & LIVING EXPENSES

MONTHLY RENT / MORTGAGE $

UTILITIES $

GROCERIES/FOOD $

TRANSPORTATION $

HEALTHCARE $

CHILD CARE / BABYSITTING $

ALIMONY / CHILD SUPPORT$

LOAN PAYMENTS $

CREDIT CARDS $

OTHER $

TOTAL MONTHLY EXPENSES $

INSURANCE BENEFITS INFORMATION & PATIENT RESPONSIBILITIES

*****PLEASE MAKE SURE THE BELOW INFORMATION IS COMPLETE & SIGNED*****

NAME OF PRIMARY INSURED: *

CHILD'S SOCIAL SECURITY #

INSURED RELATIONSHIP: *

Self
Spouse
Dependent

INSURANCE CARRIER NAME: *

INSURANCE CARRIER ADDRESS:

INSURED MEMBER ID # *

INSURANCE CARRIER PROVIDER PHONE *

NAME, ADDRESS, & PHONE # OF PERSON RESPONSIBLE FOR BILL IF OTHER THAN APPLICANT:

DO YOU HAVE SECONDARY INSURANCE: *

SECONDARY INSURANCE CARRIER AND PHONE NUMBER:

In-Network Insurances Please be prepared to pay before each appointment. You are responsible for any deductible, copay and/or coinsurance indicated by your insurance plan, including the full balance due to termination of coverage. You will be responsible for “non-covered” services as deemed by your carriers. NOTE: Some insurance carriers may require that you notify them of your visit with us. Please contact them to avoid additional financial responsibility.

Out-of-Network Insurances Please be prepared to pay before each appointment. You are responsible for 100% of the fee.

SIGNATURE OF POLICY HOLDER *

DATE *

UPLOAD YOUR INSURANCE CARDS - FRONT AND BACK

Click or drag files to this area to upload. You can upload up to 4 files.

Upload a scan of your Insurance cards, both front and back.

Website

Once you have completed this form, you will be redirected to Step 2: Patient Consent for Limited Email and Text Communications