Psychiatric New Patient Form
Please fill out the following questions completely.
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Email *
Date and time of appointment *
DEMOGRAPHIC INFORMATION
First and Last name *
Date of birth *
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Age *
Gender *
Ethnicity *
Highest level of education *
Occupation *
Address: *
Cell phone *
Home phone *
Work phone
EMERGENCY CONTACT INFORMATION:
Name of emergency contact *
Emergency Contact phone *
Relation to Emergency Contact *
Emergency Contact address
Emergency contact email address *
Are you currently on disability or SSI? If yes, please specify: *
Relationship/marital status *
EXTERNAL HEALTH CARE PROVIDERS INFORMATION
Primary Care Physician name, address, phone number *
Psychiatrist name, address, phone number. Leave blank if none.
Therapist name, address, phone number. Leave blank if none.
How did you hear about us? *
Pharmacy name, address and phone number
I authorize the Center for Therapy & Counseling Services, LLC, to release a summary of my visit and treatment plan to the following selected members of my care team periodically and as needed to keep them appraised of my behavioral health status and treatment plan. This helps with coordination of my care. I understand that I can revoke this authorization at any time by submitting a written request. Please select all that apply:
Type name below to authorize the above consent for self or minor child or dependent adult:
Date *
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ACCESS TO APPOINTMENT AND ACCOUNT INFORMATION
(Leave this section blank if you do not wish to give permission for access to your appointment or account information. No verbal requests will be accepted for this per HIPAA regulation).
I give permission to share my appointment and account information for a period of 1 (one) year to the following person(s). I may withdraw my permission in writing at any time. Please enter names and phone numbers:
By entering my name below, I authorize the Center for Therapy & Counseling Services, LLC, to share my appointment and account information with the person(s) listed above for the period of one year.
Date
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In your own words describe why you are meeting with the doctor today. *
PERTINENT SOCIAL INFORMATION
Current family structure: *
Required
Family structure when growing up: *
Required
Where were you born and raised? *
Were there any problems with your birth or early childhood? If yes, please specify.
Have you experienced any traumatic events? *
Do/did you have any legal problems currently or in the past? *
Please list any issues that are currently worrying you or causing stress in your profession/workplace, personal relations, finances, career, grades, etc.
PERTINENT FAMILY INFORMATION
Father's Age, living or deceased:
Father: If deceased, age and cause of death
Father's psychiatric problems, if any
Mother's Age, living or deceased:
Mother: if deceased, age and cause of death
Mother's psychiatric problems, if any
Sibling(s) age(s), living or deceased:
Sibling: if deceased, age and cause of death
Sibling(s) psychiatric problems if any
Children: ages, living or deceased
Children: if deceased, age and cause of death
Extended Family - any psychiatric problems in grandparents or first cousins?
PERTINENT PSYCHIATRIC/MENTAL HEALTH INFORMATION
Please list all psychiatric hospitalization if any: Hospital/reason/dates of stay
Have you ever had psychotherapy? *
If yes, name of therapist
Have you ever had TMS therapy? *
If yes, outcome?
Have you ever had ECT? *
If yes, outcome?
SUBSTANCE ABUSE
This section pertains to substances such as: Caffeine, Tobacco, Cigarettes, Vaping, Alcohol, Cannabis, Drugs etc.
1. Substance
Age when you first started using this substance
How much and how often do you use this substance?
When did you last use this substance?
Do you currently use this substance?
Clear selection
2. Substance
Age when you first started using this substance
How much and how often do you use this substance?
When did you last use this substance?
Do you currently use this substance?
Clear selection
3. Substance
Age when you first started using this substance
How much and how often do you use this substance?
When did you last use this substance?
Do you currently use this substance?
Clear selection
4. Substance
Age when you first started using this substance
How much and how often do you use this substance?
When did you last use this substance?
Do you currently use this substance?
Clear selection
5. Substance
Age when you first started using this substance
How much and how often do you use this substance?
When did you last use this substance?
Do you currently use this substance?
Clear selection
Past alcohol and drug abuse treatment
Clear selection
If any past alcohol and drug treatment please list when and where you received treatment.
MEDICAL HISTORY
Please list all non-psychiatric hospitalizations if any:
Please list all surgical history if any:
Do you now or ever had the following conditions? Please select all that apply.
Other medical conditions not listed above:
Please any medications/substances you are allergic to:
Please list all medications you take including dosage:
Please list any psychiatric medications you have taken in the past:
Height: *
Current weight: *
POLICIES
MISSED APPOINTMENTS: Please be advised that the Center for Therapy & Counseling Services has a missed appointment policy that is strictly enforced. The normal fee for the service will be charged directly to the patient/client's payment on file. We require that you contact our offices 24 hours in advance during the business week to cancel or change your appointment. *
MEDICATION REFILL REQUESTS:  It is your responsibility to be sure you schedule your next visit so that you see the doctor before you run out of medication. Refill requests will not be authorized without seeing your provider. It is imperative that you keep your scheduled appointments. *
PRIVACY IN OUR OFFICES: For the protection of our patients/clients and staff, any activity that may be considered an invasion of privacy while in our offices will result in discharge of the offender from our practice. These activities include, but are not limited to, photography, recording of conversations, or similar behavior.
Clear selection
FINANCIAL POLICY: Full payment of your financial responsibility is due at the time of service. We accept credit cards. The psychiatrist is out of network with insurance companies. We will provide you with itemized invoices which you can submit to your insurance company. If you submit claims to your insurance company for reimbursement you are responsible for understanding your plan benefits and rates of reimbursement. Payment is expected at time of service. A credit card must be kept on file. *
I understand that I am responsible for my entire fee. *
Required
In the event that my account becomes delinquent and is forwarded to an attorney for collection, I am responsible for the attorney fees and all court costs. *
I will be responsible for full payment of the missed appointment fee when 24 hours’ notice is not given for cancellation. *
I give my full consent to the Physician and Psychotherapists within the group to exchange information to facilitate treatment. *
I give permission for the Center for Therapy & Counseling Services and its clinical employees and/or independent contractors to give me Psychiatric treatment. *
I understand that I can revoke this consent at any time with written notice. *
I have the right to receive copies of all documents I signed today as part of the registration procedure. *
I understand the policies regarding Missed appointments, Medication refill requests, Privacy in our offices and Financial policies. *
HIPAA - the Center for Therapy & Counseling Services makes every effort to adhere to HIPAA Privacy and Security Rules. Your Private Healthcare Information is disclosed only under the following situations:
1. You or your authorized representative have authorized specific information to be shared. *
2. When you have the opportunity to agree or object, such as when you bring another person into your session. *
3. Related to otherwise permitted use. *
4. For purpose of public health research. *
Date of form completion: *
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Name of patient or guardian of patient completing this form: *
CONTROLLED SUBSTANCE USE AGREEMENT
I understand that I/my dependent may be diagnosed with or treated for a medical condition that requires use of controlled substance medication(s) (benzodiazepines, stimulants, etc.) because this medical condition has not been adequately managed with non-controlled medications and my function is limited by this medical condition. I understand that the intent of this medication is to increase my/my dependent’s ability to function, though the controlled substance medication is unlikely to eliminate my/ my dependent’s condition. *
I/my dependent will take the medication only as prescribed. I/my dependent will not take any additional sedatives, alcohol or other pain medications without the prior approval of my provider. *
I/my dependent understand that the medication will be prescribed only according to the agreed upon schedule. Prescriptions will be provided only during regular business hours. Medications will not be called in to the pharmacy. *
I/my dependent will not seek or accept any additional controlled substance medications (i.e. pain, anxiety or stimulants) other than those prescribed by my provider. This includes prescriptions from other providers, medications borrowed or accepted from family or friends and any illicit or street drugs. *
Medication refills will be provided as written prescriptions only. No refills will be given prior to 30 days. I understand that I must make appointments with my provider at least every (3) months or sooner if my provider recommends. No refills will be given if I do not keep these appointments. Two (2) no show appointments will constitute grounds for immediate dismissal from the practice. *
I understand that my provider is under no obligation to provide these medications to me, and that he/she reserves the right to discontinue these medications at any time. If I refuse, I understand the medications will be stopped. *
I understand that lost or stolen medications will not be refilled under any circumstances. It is my responsibility to protect and secure my medications. This includes keeping the medication out of reach of children. A copy of a police report will be required for any lost or stolen controlled substance prescriptions. *
I understand that my provider may request specialist evaluation of my treatment and I agree to keep appointments. My provider will send a copy of my medical record and care to the referred physician. *
I understand that my provider by law is required to report all controlled substances dispensed to me to the state monitored prescription monitoring program. *
Name of patient or guardian of patient completing this form: *
Date of form completion. *
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TERMINATION OF TREATMENT
In addition to the above agreements, I accept the right of my provider's staff to terminate this agreement for any of the following reasons:
1. I seek or obtain any pain medication from a source other than my provider. *
2. I, in any way, attempt to forge or alter a prescription. *
3. I distribute my prescribed medication(s) to any other person. *
4. My medical condition declines to the point at which, in the judgment of my provider, continued therapy with this medication presents danger to my wellbeing or safety. *
5. There is evidence that I am no longer receiving a reasonable therapeutic benefit from the medication, ormy provider determines that I am no longer a good candidate to continue the medication. *
I understand that by signing this agreement, I must abide by the rules reviewed above and that failure to abide by these agreements will result in termination of medication prescriptions and immediate dismissal from my provider and the practice. *
Required
I understand that if I default from this agreement and I am having a medical condition I should call 911 or go to the nearest emergency room. *
Name of patient or guardian of patient completing this form: *
Date of completion of this form *
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