Forms – CBC Child Enrollment

Community Bridge Clinic Enrollment - Child

Patient Information

Full Legal Name of Person Receiving Services(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Sex(Required)

Female

Male

Other

Ethnicity(Required)

Hispanic

Non-Hispanic

Race(Required)

Patient's Primary Language(Required)

Does the patient attend school?(Required)

Yes

School child attends(Required)

Grade(Required)

Insurance Information

Do you have insurance (private/Medicaid/Husky)?(Required)

Yes

Medical Insurance

Medicaid ID#

Insurance Address

Street Address Address Line 2 City State ZIP Code

Insurance Phone # (on back of card)

Policy Holder Name(Required)

First Last

Policy Holder Date of Birth(Required)

Is there additional insurance?(Required)

Yes

Private Insurance ID/Policy #

Group Number

Insurance address(Required)

Street Address Address Line 2 City State ZIP Code

Insurance Phone # (on back of card)

Policy Holder Name(Required)

First Last

Policy Holder Date of Birth(Required)

Parent/Guardian Information

Parent/Guardian Name(Required)

First Last

Relationship to Patient(Required)

Date of Birth(Required)

Address (if different from patient)

Street Address Address Line 2 City State ZIP Code

I agree voicemail messages can be left for me on:(Required)

Home phone

Cell phone

Work phone

Home phone

Cell phone

Work phone

Parent/Guardian Email

Child's Cell Phone # (if relevant)

Child's Email (if relevant)

Child's Primary Care Provider Name

Primary Care Provider Phone

Child's Dentist Name

Dentist Phone

Has your child seen this dentist/group for 1+ year(s)

Yes

Second Emergency Contact

Name

First Last

Relationship to Student

Phone

Medical History

Date of last physical exam?

Does the patient have any medical conditions?(Required)

Yes

Explain(Required)

Does the patient take any medications (including inhalers or vitamins)?(Required)

Yes

Explain(Required)

Has the patient had any serious injuries (including a head injury)?(Required)

Yes

Explain(Required)

Does the patient have a birth or heart defect?(Required)

Yes

Explain(Required)

Has the patient ever been hospitalized overnight?(Required)

Yes

Explain(Required)

Has the patient had any surgery in the past?(Required)

Yes

Explain(Required)

Does the patient have any problems with sleeping and/or snoring?(Required)

Yes

Explain(Required)

Has the patient had a dental cleaning within the past 6-12 months?(Required)

Yes

Approximate date of last cleaning(Required)

Does anyone smoke in the home?(Required)

Yes

Does the patient smoke, use e- cigarettes, or chew tobacco?(Required)

Yes

Does the patient get 60 min of exercise at least 3 times a week?(Required)

Yes

Are you concerned with the amount of time your child spends on social media, T.V., video games, computer, or phone?(Required)

Yes

Explain(Required)

Any other concerns about your child’s health or weight?(Required)

Yes

Explain(Required)

Patient History of the Following:

Anemia/Blood disorders(Required)

Yes

Asthma(Required)

Yes

Autism(Required)

Yes

COVID 19(Required)

Yes

Cancer/Leukemia(Required)

Yes

Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required)

Yes

Digestive issues/Diarrhea/Constipation(Required)

Yes

Headaches/Migraines(Required)

Yes

Learning/Developmental Issues(Required)

Yes

Seasonal Allergies(Required)

Yes

Heart murmur(Required)

Yes

Skin problems (eczema, acne, etc.)(Required)

Yes

Seizures(Required)

Yes

Overweight or Obesity(Required)

Yes

Other Patient History:

Family History - Please Note Relationship to Patient

Anemia/blood disorders(Required)

Yes

Relationship to Patient(Required)

ADD/ADHD(Required)

Yes

Relationship to Patient(Required)

Asthma(Required)

Yes

Relationship to Patient(Required)

Cancer/Leukemia(Required)

Yes

Relationship to Patient(Required)

Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required)

Yes

Relationship to Patient(Required)

Headaches/ Migraines(Required)

Yes

Relationship to Patient(Required)

Overweight/ Obesity(Required)

Yes

Relationship to Patient(Required)

Skin problem (acne, eczema, etc.)(Required)

Yes

Relationship to Patient(Required)

Mental Health Issues(Required)

Yes

Relationship to Patient(Required)

Seizures(Required)

Yes

Relationship to Patient(Required)

Heart Disease(Required)

Yes

Relationship to Patient(Required)

Hypertension(Required)

Yes

Relationship to Patient(Required)

Substance Use(Required)

Yes

Relationship to Patient(Required)

Tobacco Use(Required)

Yes

Relationship to Patient(Required)

Other Family History:

Allergies

Any foods (including lactose intolerance)?(Required)

Yes

Explain(Required)

Any medications? (including over the counter or antibiotics)(Required)

Yes

Explain(Required)

Does the patient have an Epi-Pen (or similar prescription) at home/school?(Required)

Yes

Explain(Required)

Other Allergies:

Behavioral Health

Has the patient ever had or is currently receiving counseling services(Required)

Yes

With CFA?(Required)

Yes

Other

When and with whom?(Required)

Are you interested in receiving information about mental health counseling for your child?(Required)

Yes

Has the patient ever had any of the following:

Family changes(Required)

Yes

School issues(Required)

Yes

Social/peer stresses(Required)

Yes

Anxiety/Panic Attacks(Required)

Yes

Learning Disabilities(Required)

Yes

Anger issues(Required)

Yes

ADHD/Attention issues(Required)

Yes

Depression(Required)

Yes

Truancy/School avoidance

Yes

Recent loss/crisis(Required)

Yes

By signing below, I understand and acknowledge I have read and understand this consent:(Required)

I give permission for my child to obtain routine health services at the Community Bridge Clinic. All insurances will be billed at the time of visit. Sliding scale for payment available for those without medical insurance

RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION(Required)

I authorize the release of any medical or behavioral health information necessary to process my claim. I also authorize payment of health benefits to Child & Family Agency for services provided.

CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES(Required)

I understand and acknowledge that I have read and understand this consent and I have received CFA’s Notice of Privacy Practices currently in effect. I understand that information regarding how CFA will use and disclose my information can be found in CFA’s Notice of Privacy Practices. I understand my consent is effective for as long as CFA maintains my protected health information.

AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION

I give permission to allow Child & Family Agency (CFA) to exchange as needed information with my child’s medical provider in order to effectively care for my child. I understand that CFA medical and mental health providers may communicate with each other about my child’s care if indicated.

I also certify that the health information provided is accurate to the best of my knowledge and understand that incorrect information can be dangerous to the patient’s health. I will notify the Community Bridge Clinic of any changes to medical information. By signing below, I understand that this authorization is valid until I revoke this authorization. I understand I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent.

Signature of Parent/Legal Guardian/Personal Representative (or Student if over 18 years old):(Required)

Signature Date(Required)