Instructions to Parents: Please fill out to the best of your knowledge. Write N/A if not applicable to your child. Circle appropriate answers where indicated. Add any additional comments if you wish.
Pregnancy with This Child- (Check Appropriate Answer)
Past Medical History
School History (if applicable)
Has The School Reported Problems With:
Family History (Under Parents List Names Of Children In Order Of Birth)
Did Any One In Family (Including Relatives) Have:
Thank you for choosing me as your mental health care provider. I am committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of the Financial Policy, which you are required to read and sign prior to any treatment.
All patients must complete our Information and Insurance form before seeing the doctor.
Appointments are scheduled for the same day and time each week unless altered by the doctor or yourself
I understand that payment is expected upon receipt of service.I agree to pay 1.5% per month if I am delinquent in my
account and have to be re-billed. I also understand that should any action need to be taken to collect for professional services rendered, the professional provider shall be entitled to recover any attorney fees.
We cannot bill your insurance company unless you give us your insurance information. We are
not a party to that contract. We require that you be pre-approved and we will do so as a courtesy.
Whatever portion your insurance does not pay will automatically be transferred to your bill.
Please be aware that some, and perhaps all, of the services provided may not be considered
reasonable and necessary under your insurance plan.
Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary
for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual
and customary rates.
Adult patients are responsible for full payment at time of service.
The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment. For
unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-paid by credit card or
We require, at least 24 hours in advance, to cancel an appointment. Any calls made after 5:00pm or on Saturdays
and Sundays to cancel appointments will not be accepted .Thus, if your appointed is after five o’clock, you must call
before five o’clock on the previous day. If your appointment is on a Monday, you must call before 5:00pm on the previous Friday. Please help us serve you better by keeping scheduled appointments.
Unless it is an emergency, all therapeutic contacts take place in the office. Should you request therapeutic interventions
on the telephone you will be charged $225 per hour prorated in .10 hours. Most insurance companies will not reimburse
Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns. I have read the Financial Policy. I understand and agree to this Financial Policy:
I hereby certify and I understand the above and have been informed of policies and procedures regarding appointments and fees. Furthermore, I authorize treatment by Wade H. Silverman
Our practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. We also are required by law to keep your information private. These laws are complicated, but we must give you this important information. This pamphlet is a shorter version of the full, legally required NPP and you may have a copy of this to read and refer to it for more information. However, we can’t cover all possible situations so please talk to our Office Manager (see the end of this pamphlet) about any questions or problems.
We will use the information about your health, which we get from you or others mainly to provide you with treatment, to arrange payment for our services, and for some other business activities, which are called, in the law, health care operations. After you have read this NNP, we will ask you to sign a consent form to let us use and share your information. If you do not consent and sign this form,
we cannot treat you.
If you or we want to use or disclose (send, share release) your information for any other purposes, we will discuss this with you and ask you to sign an authorization form to allow this.
Of course we will keep your health information private, but there are some times
when the laws require us to use or share it. For example:
There are some other situations like these but which don’t happen very often. They are described in the longer version of the NPP.
If you have any questions regarding this notice or our health information privacy policies, please contact the Psychologist who is Dr. Wade H. Silverman and can be reached by phone at 305-669-3605.
The effective date of this notice is April 30, 2003.
Also, you may have other rights, which are granted to you by the laws of our state and these may be the same or different from the rights described above. We will be happy to discuss these situations with you now or as they arise.
Child Anxiety Scale (CAS)
Children’s Color Trail Test
Conners Rating Scale
Million Adolescent Clinical Inventory (MACI)
Minnesota Multiphasic Personality Inventory (MMPI-A)
Million Pre-Adolescent Clinical Inventory (MPACI)
Piers-Harris Children's Self-Concept Scale 2
Revised Children's Manifest Anxiety Scale (RCMAS-2)
Reynolds Adolescent Depression Scale-2 (RADS-2)
Reynolds Child Depression Scale-2 (RCDS-2)
Wechsler Intelligence Scale for Children (WISC-IV)
Cancellations must be made 24 hours in advance. Patients will be charged for the session if they do not call and cancel.