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103 Rossmore Pl.

Augusta, GA 30909

Office (706) 364-7165

Fax (706) 869-7600

Transitions of Augusta M. Kevin Turner, Ph. D. Licensed Psychologist GA License: 1589

We have enclosed our new patient paperwork and directions to our office.

Please complete the packet PRIOR to the appointment. If you need to cancel

or reschedule an appointment please do so 48 hours PRIOR to the

appointment.

Patients are responsible for bringing insurance cards to the

appointment. If you do not have a copy of the card it is the

patient’s responsibly to obtain that PRIOR to the

appointment.

Please be advised that it is ALWAYS a patient’s responsibility to contact their

insurance company to check their Mental Health Benefits and to verify if a

Provider is in network PRIOR to their appointment.

The information you may need to verify this is listed below:

Maxwell Kevin Turner Ph.D. Tax ID: 134268905

**Please note that if you are presenting with a minor patient and are not the

biological parent, you must bring legal documentation of

guardianship/custody status and/or signed authorization from the

parent/guardian granting you permission to treat the child.

We look forward to seeing you at your appointment.

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Client Information (Please print clearly and complete ALL blanks)

_________________________________________________________ ___________ _____ _______ ______ Last Name First Middle Date of Birth Age Gender Race ________________________________________________ ____________________________________________ Home Address Apt. City State Zip Code _____________________________ _________________________ ____________________________________ Best Contact Number Alternate Phone Number Email Address ______________________________ ___________ ______________________________________________ Social Security Number Martial Status Employer/School _____________________________ _______________________ ________________ _______________________ Primary Care Physician Emergency Contact Phone Number Relationship

Parent/Legal Guardian Information

Mother/Legal Guardian: _____________________________ Best Contact Number:_________________

Father/Legal Guardian: ______________________________ Best Contact Number: _________________

Primary Insurance Information ______________________________ ____________________________ ________________________ Policy Holder’s Name Insured SSN (if different from above) Subscriber Date of Birth

__________________________ ______________________________ ____________________________

Relationship to Patient Insurance Company Policy Number

Secondary Insurance

______________________________ ____________________________ ________________________ Policy Holder’s Name Insured SSN (if different from above) Subscriber Date of Birth

__________________________ ______________________________ ____________________________

Relationship to Patient Insurance Company Policy Number

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Child History PARENT QUESTIONNAIRE Date: ___________________________

Family Data (to be filled out by parents)

Child’s Name: _______________________________ Birthdate: _________ Age: ______ Grade: _______

Father’s Name: ______________________________ Age: __________ Education: __________________

Father’s Employer: _____________________________________________________________________

Mother’s Name: _____________________________ Age: __________ Education: __________________

Mother’s Employer: ____________________________________________________________________

Parents are: Married ____ Divorced ____ Separated ____ Widowed ____ Single ______

Date _______ Date ________ Date _________ Date ________ Date _______

Child lives with: Both Parents _____ Mother _____ Father _____ Other _____

Is this a foster home placement? Yes_____ No _____ Adopted? Yes _____ No ______

List the Names, Ages, And Highest Grades Attended of Siblings:

Sibling Name Age Highest Grade Attended

List other Relatives or People Living at Home:

Name Relation

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PREGNANCY HISTORY- MOTHER

During this pregnancy did you have? Yes No When Describe

Medication during pregnancy?

Emotional problems?

Threatened miscarriage or early

contractions?

Alcohol, drugs, tobacco use?

Other medical problems?

BIRTH HISTORY

How long was labor? ___________________________________________________________________

Was the delivery unusual in any way? Yes________ No_______ If yes how? ______________________

Did you have a cesarean? Yes_________ No_________ Complications? ___________________________

Was the baby’s color normal? Yes________ No_______ Blue? ______ Yellow? ______ Don’t know_____

Was the baby premature? Yes________ No_______ How much? ________________________________

Did you take the baby home with you from the hospital? Yes______ No______ How long after? ______

DEVELOPMENT (indicate child’s age)

Walked: ________________ Made Sounds: _____________ First spoke: __________________________

First Short Sentences: _____________________________________ Out of diapers: _________________

Any period of failure to grow or unusual growth? _____________________________________________

Do you consider your child’s speech and language development similar to other children’s?

Yes__________ No___________ If No, please explain: ________________________________________

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MEDICAL HISTORY

Yes No When Describe

Hospitalizations

Allergies (especially to

medicine)

Major Illness

Frequent accidents requiring

doctor’s care

Current Medications

Do you consider your child’s activity and energy level to be: Low_______ Average________ High______

As compared with other children of the same age, do you think your child’s general development is:

Below Average?______________ Average?__________________ Above Average? __________________

Describe child’s appetite and eating habits at present: _________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Describe child’s sleeping pattern now. Are there nightmares or night terrors now or in the past?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

What have you found to be the most effective form of discipline? _______________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Is the discipline at home handled mostly by: Mother_________________ Father_________________

Describe how the child reacts to discipline. Any stubbornness? __________________________________

_____________________________________________________________________________________

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How does your child get along with children not in the family? A leader? Follower? Playing with children

who are older? Younger? ________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

What is the age and sex of your child’s favorite playmate? _____________________________________

Describe any moody periods: _____________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Describe any problems with awkwardness or clumsiness: ______________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Describe any problems in sitting still or paying attention: ______________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

EDUCATIONAL INFORMATION

School Attending: ___________________________________ Teacher: ___________________________

Child’s Present Grade: _________________ Has child repeated a grade? __________________________

Have there been many changes in the child’s school setting? Yes__________ No___________

If Yes, Explain: _________________________________________________________________________

_____________________________________________________________________________________

Did the child have difficulty leaving home or parents upon entering pre-school or first grade?

Yes__________ No___________ If Yes, explain: ______________________________________________

_____________________________________________________________________________________

Did he/she enjoy and feel successful in school? ______________________________________________

Please explain: ________________________________________________________________________

_____________________________________________________________________________________

Has/does your child receive special education services or private tutoring? ________________________

_____________________________________________________________________________________

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PHYSICIAN INFORMATION

When did the child last have a physical examination? _________________________________________

Is the child taking any form of medication? Yes________ No__________ If yes, what kind and the

reason: ______________________________________________________________________________

_____________________________________________________________________________________

Name of Pediatrician or Physician: _________________________________________________________

Have there been any previous psychological evaluations? Yes _______________ No________________

If yes, please indicate the following: Date of Evaluation:_________________ Provider:_______________

Diagnosis: ____________________________________________________________________________

Have there been any previous psychiatric, neurological, CT, MRI, or EEG evaluations? Yes_____ No_____

If yes, please indicate the following: Date of Evaluation:_________________ Provider:_______________

Diagnosis: ____________________________________________________________________________

What do you think are your child’s major problems? __________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

When did you first notice your child’s problems? _____________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

In what ways do you think this clinic could be most helpful with your child? _______________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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ON THE FOLLOWING, PLEASE CHECK ALL THE ITEMS LISTED BELOW THAT APPLY

TO YOUR CHILD. IF YOUR CHILD IS ON MEDICATION NOW, PLEASE ANSWER

BASED ON PRE-MEDICATION BEHAVIOR.

OPPOSITIONAL DEFIANT DISORDER (ODD)

A pattern of negativistic, hostile, and defiant behavior lasting at least six months, during which four of

the following items are present.

□ Often loses temper

□ Often argues with adults

□ Often actively defies or refuses to comply with adult’s request or rules

□ Often deliberately annoys people

□ Often blames others for his or her mistakes or misbehavior

□ Is often touchy or easily annoyed by others

□ Is often angry and resentful

□ Is often spiteful and vindictive

GENERALIZED ANXIETY DISORDER

The anxiety and worry are associated with three (or more of the following six symptoms, with at least

some symptoms present for more days than not for the past six months). Note: Only one item is

required in children.

□ Restlessness or feeling keyed up or on edge

□ Being easily fatigued

□ Difficulty concentrating or mind going blank

□ Irritability

□ Muscle tension

□ Sleep disturbance

□ Racing thoughts

□ Headaches

□ Stomach aches

□ Dizziness

□ Blurring vision

□ Trouble breathing

□ Heart racing

□ Excessive sweating

□ Ringing in ears

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DYSTHYMIA

Presence (while depressed) of two of the following six symptoms.

□ Poor appetite or overeating

□ Insomnia or hypersomnia

□ Low energy or fatigue

□ Low self-esteem

□ Poor concentration or difficulty making decisions

□ Feelings of hopelessness

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

Six or more of the following symptoms of inattention have persisted for at least six months to a degree

that is maladaptive and inconsistent with developmental level.

INATTENTION

□ Often fails to give close attention to details or often makes careless mistakes in schoolwork,

work, or other activities.

□ Often has difficulty sustaining attention in tasks or play activities.

□ Often does not seem to listen when spoken to directly

□ Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in

the workplace.

□ Often has difficulty organizing tasks and activities

□ Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

□ Often loses things necessary for tasks and activities

□ Is often easily distracted by extraneous stimuli

□ Is often forgetful in daily activities

Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least six months

to a degree that is maladaptive and inconsistent with developmental level.

HYPERACTIVITY

□ Often fidgets with hands or feet or squirms in seat

□ Often leaves seat in classroom or in some situations in which remaining seated is expected

□ Often runs about or climbs excessively in situations in which it is inappropriate

□ Often has difficulty playing or engaging in leisure activities quietly

□ If often “on the go” or often acts as if “driven by a motor”

□ Often talks excessively

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IMPULSIVITY

□ Often blurts out answers before questions have been completed

□ Often has difficulty awaiting turn

□ Often interrupts or intrudes on others

ADDIONTIONAL COMMENTS: ____________________________________________________

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By signing below I am swearing that I am the legal guardian of this child:

___________________________________________________________________Parent or Legal Guardian signature Date

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AUTHORIZATION FOR RELEASE OF INFORMATION (Please print)

Patient Name: _________________________________________________________________________ SSN#: ______________________________ Date of Birth: ______________________________________

I hear by authorize M. Kevin Turner, Ph.D. to release to/or obtain from:

Name of Person/Agency: ________________________________________________________________ Mailing Address: _______________________________________________________________________ _______________________________________________________________________ Telephone Number: ____________________________ Fax Number: _____________________________

INFORMATION TO BE RELEASED/OBTAINED FROM MEDICAL RECORDS:

____ Face Sheet ____ Medication Records ____ Discharge Summary ____ X-Ray Orders ____ History & Physical ____ Physician Orders ____ Admission History/Mental Status Exam ____ EKG Notes ____ Psychological Evaluation (s) ____ Diagnosis ____ Education Evaluation (s) ____ Admission/Discharge Dates ____ Discharge/Aftercare Plan ____ Lab Reports ____ Physician Weekly Progress Reports ____ Treatment Plan (s) ____ Other (Please specify): ______________________________________________________________ _____________________________________________________________________________________ For the purpose of: _____________________________________________________________________

This consent is given freely and voluntarily. Any information shall be released by the recipient without my written consent, except as mandated by State and Federal Law. In the event that information is released by a third party to unauthorized persons, the undersigned hereby releases the provider from any and all liability for such unauthorized release. I understand I may withdraw this consent at any time. This consent will expire on _______________ or 90 days from the date below, or sooner at my election. _____________________________________________ _____________________________________ Patient’s Signature Date Signature of Legal Guardian Date _____________________________________________ ______________________________________ Signature of Witness Date Relationship to Patient

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AUTHORIZATION CONSENT TO TREAT A MINOR

I __________________________________________ am Parent/Legal Guardian of

_____________________________________ who is a patient of Kevin Turner

Ph.D.

Biological Mother’s Name: ____________________________________________

Biological Father’s Name: _____________________________________________

I am authorizing/refusing release of any medical information.

__________________________________________ Mother ( ) Authorized

( ) Not Authorized

__________________________________________ Father ( ) Authorized

( ) Not Authorized

__________________________________________ Other ( ) Authorized

( ) Not authorized

Signed by: __________________________________________________________

Date: ______________________________________________________________

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AUTHORIZATION CONSENT FORM

HIPPA AGREEMENT

The HIPAA Privacy Rule provides federal protections for individually identifiable health

information held by covered entities and their business associates and gives patients an array of

rights with respect to that information. At the same time, the Privacy Rule is balanced so that it

permits the disclosure of health information needed for patient care and other important

purposes. The Security Rule specifies a series of administrative, physical, and technical

safeguards for covered entities and their business associates to use to assure the

confidentiality, integrity, and availability of electronic protected health information. (See

www.transitionsofaugusta.com for additional details)

I have read and agree to the Patient Service/HIPPA Agreement provided to me by Transitions of

Augusta. I have read and understand the Georgia Notice of Psychologist’s Policies and Practices.

_____________________________________________________________________________________Signature Date

TREATMENT AUTHORIZATION

I ___________________________________________ (Patient Name) authorize M. Kevin

Turner Ph.D. to provide Psychological Services or Testing.

INSURANCE AUTHORIZATION

I authorize M Kevin Turner Ph.D. (Transitions of Augusta) the release of any medical or other

information necessary to process medical claims. I authorize payment of medical benefits to be

paid to M. Kevin Turner Ph.D. (Transitions of Augusta) for services provided.

_____________________________________________________________________________________

Signature Date

Cancelation Policy

I understand it is my responsibility to contact Transitions of Augusta 48 HOURS PRIOR to my

appointment to cancel or reschedule. I will be charged a $60 fee for missed appointments

without 48 hour prior notification.

_____________________________________________________________________________________

Signature Date

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Directions to Transitions of Augusta, P.C Kevin Turner, Licensed Psychologist

103 Rossmore Place, Augusta, GA 30909. (706) 364-7165

We are located behind the Double Tree Hotel (formerly the Sheraton) and next to the Augusta

Corporate Center (location of the IRS). Please allow extra time to locate the office.

From Blythe, Hephzibah, Deans Bridge, Tobacco Road area- Take U.S. 1

(Deans Bridge Rd.) to the 520 (Bobby Jones Expwy) Take 520 (Bobby Jones Expressway) west to Wheeler Rd. exit #1C and make a left at the stop light. Go ½ a mile and make a right at the 2nd stop light (across from the Waffle House) onto Perimeter Parkway. Follow Perimeter Parkway around the curve to Whitney Place (Between the Double Tree Hotel and the Augusta Corporate Center). Go about 0.2 miles, over a small hill and the offices will be to the right. (Rossmore Place; inside a small cul de sac) We are the office in the middle.

From Washington Rd., area – Take Washington Rd. to the 520 (Bobby Jones

Expressway). Take the 520 (Bobby Jones Expwy) about 2 miles to exit #1C Wheeler Road. Make a left at the traffic light and a right at the next traffic light (across from the Waffle House) onto Perimeter Parkway. Follow Perimeter Parkway around (pass the Montessori School of Augusta) and make a left onto Whitney Place (Between the Double Tree Hotel and the Augusta Corporate Center). Go about 0.2 miles and the building will be on the right (Rossmore Place; inside a small cul de sac) We are the office in the middle.

From South Carolina – Take I – 20 going westbound into Georgia. Take Exit

#196A towards 520 Bobby Jones Expressway. Take the 520 (Bobby Jones Expressway) to exit # 1C Wheeler Road. Make a left at the traffic light and a right at the next traffic light (across from the Waffle House) onto Perimeter Parkway. Follow Perimeter Parkway around (pass the Montessori School of Augusta) and make a left onto Whitney Place (Between the Double Tree Hotel and the Augusta Corporate Center). Go about 0.2 miles and the building will be on the right (Rossmore Place; inside a small cul de sac) We are the office in the middle.

From Downtown Augusta, Walton Way area – Take Walton Way to the

Walton Way Ext. and bear to the right. Make a left at the traffic light onto Wheeler Rd. and keep straight about 1 mile (Past O’Charlie’s). Make a right at the 4th traffic light (across from the Waffle House) onto Perimeter Parkway. Follow Perimeter Parkway around (pass the Montessori School of Augusta) and make a left onto Whitney Place (Between the Double Tree Hotel and the Augusta

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Corporate Center). Go about 0.2 miles and the building will be on the right (Rossmore Place; inside a small cul de sac) We are the office in the middle.

From Thomson, Grovetown, Lincolnton area – Take I-20 East to exit # 195

Wheeler Road. Make a right onto Wheeler Road for about 1mile. Make a left at the traffic light (across from the Waffle House) onto Perimeter Parkway. Follow Perimeter Parkway around (pass the Montessori School of Augusta) and make a left onto Whitney Place (Between the Double Tree Hotel and the Augusta Corporate Center). Go about 0.2 miles and the building will be on the right (Rossmore Place; inside a small cul de sac) We are the office in the middle.