Online Paperwork - Psychiatric Services P.C.

Paperwork Instructions

Please reserve at least 20 minutes to complete this paperwork.

"*" indicates required fields

1Patient Information

2Employment Information

3Emergency Contact Information

4Insurance Information

5Family History

6Your Education

7Personal Medication

8Medical Information

9Mental Health History

10Mental Health Information

11Release of Information

12Privacy Practices and Treatment Agreement

First Name*

Last Name*

Goes by

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Email Address*

Sex*

Male

Female

Gender/Pronoun

Date of Birth*

Month

Day

Year

Age*

Social Security Number*

Race*

White/Caucasian

Black/African-American

American Indian/Alaska Native

Asian

Nat. Hawaiian/Pacific Islander

Declined

Unknown

Other

Ethnicity*

Primary Language*

English

Spanish

Arabic

Chinese

Filipino

French

German

Greek

Hindi

Hmong

Italian

Japanese

Koren

Lithuanian

Polish

Portuguese

Russian

Somali

Vietnamese

Declined

Other

Religion*

Marital Status*

Single

Married

Separated

Divorced

Widowed

Annulled

Common Law

Domestic Partner

Living Together

Other

Do you have a POA or legal guardian?*

Yes

POA or Legal Guardian Name*

POA or Legal Guardian Address*

Street Address Address Line 2 City State ZIP Code

POA or Legal Guardian Phone*

POA or Legal Guardian Email*

Pharmacy Name*

Pharmacy Address*

Street Address Address Line 2 City State ZIP Code

Employer*

Employment Status*

Full-time

Part-time

Self-employed

Retired

Unemployed

Temporary Unemployed

Leave of Absence

Contract

Active Military Duty

Part-time Student

Full-time Student

Other

Employer's Address*

Street Address Address Line 2 City State ZIP Code

Occupation*

Indicate if student.

1st Emergency Contact Name*

1st Emergency Contact Relationship*

1st Emergency Contact Phone*

2nd Emergency Contact Name*

2nd Emergency Contact Relationship*

2nd Emergency Contact Phone*

Insurance Card (Front)

Please upload an image of the front of your insurance card.

Max. file size: 300 MB.

Insurance Card (Back)

Please upload an image of the back of your insurance card.

Max. file size: 300 MB.

Drivers License

Please upload an image of your drivers license.

Max. file size: 300 MB.

Person Responsible for Payment

First Last

Person Responsible for Payment's Address*

Street Address Address Line 2 City State ZIP Code

ALL INSURANCE COPAYS ARE TO BE PAID AT TIME OF SERVICE. All professional services rendered are charged to the patient. Our office will complete the necessary forms to help expedite insurance payments. However, the patient is responsible for all fees regardless of insurance coverage including denied or non-covered services by Medicare, Medicaid and Medicaid Managed Care Plans.

Name of Policyholder

First Last

Payment Consent*

I hereby assign payment directly to Psychiatric Services, P.C. any medical benefits for professional services rendered. I understand that I am financially responsible for my deductible, coinsurance, copayments, services received without prior authorization and any allowable charges by my insurance company/companies. I also authorize the release of information to another physician, hospital or insurance company as may be necessary for further treatment or determination of benefits and payments.

I understand and agree to the above.

Spouse Name

Spouse Employer

Spouse Occupation

Years Married

Children's Names and Ages

Who were you raised by?

Both Parents

Single Parent

Relative

Other

Father’s Name/Occupation

Mother’s Name/Occupation

Brothers/Sisters in Birth Order

Include ages.

Family history of alcoholism or substance abuse?

Include who and what substances.

Family history of mental illness?

Include who and what illness(es).

Family history of prolonged physical illness?

Include who and what illness(es).

Highest Educational Degree

Field of Study

Your complete medication history is important to your physicians. If for some reason you are unable to fill out this form, please bring in a bag all the medications (in their original containers) that you are currently taking.

Are you allergic to medications, iodine, food, tape or latex?*

List each substance you are allergic to and the reaction you experienced.

Please list all prescription and non-prescription medications, herbals, eye drops, nutritional supplements, inhalers, etc. that you use.

Include name, dose, route, directions and purpose.

Past surgeries/operations

Include description and year.

Height*

Weight (lbs)*

Check all current positive findings

Other current medical conditions

Check all that apply.

Thyroid disease

Cancer

Kidney disease

High blood pressure

Irregular heart beat/pacemaker

Seizures

Falling

Loss of consciousness

Liver disease

Chest pain

Heart attack

High cholesterol

Headaches

Osteoporosis

Asthma/COPD

Stroke

HIV/AIDS

Hepatitis

Stomach ulcer

Arthritis

Congestive heart disease

Consitutional

Weight loss

Fever

Chills

Eyes

Blurry vision

Dry eyes

Double vision

ENT

Hoarseness

Hearing loss

Nose bleeds

Swallowing problems

Cardiovascular

Chest pain

Palpitations

Swelling of legs or feet

Respiratory

Short of breath

Cough

Gastrointestinal

Nausea

Vomiting

Diarrhea

Constipation pain

Genitourinary

Increased urinary frequency

Incontinence

Skin

Rash

Hives

Hair loss

Itching

Neurological

Seizures

Tremors

Headaches/migraines

Loss of balance

Dizziness

Musculoskeletal

Joint pain

Muscle aches

Muscle weakness

Back pain

Endocrine

Increased thirst

Excessive sweating

Heat/cold intolerance

Hem/Lymphatic

Easy bruising

Swollen lymph nodes

Allergic/Immunologic

Allergic reactions

Hay fever

Frequent infections

Current Mental Health Issues

Anxious or nervousness

Panic

Phobias

Anger

Verbal fights

Sad or depressed

Crying spells

Gambling

Thoughts of self harm

Thoughts of suicice

Thoughts of hurting others

Feel mind is playing tricks

Hear things not there

See things not there

Social withdrawal

Binge

Purge

Nightmares

Weight changes

Compulsions (recurrent acts)

Obsessions (recurrent thoughts)

Mood swings

Irritable

Poor motivation

Differences based on day, month, year

Have you ever had counseling or therapy?*

Yes

Please describe.*

Have you ever been hospitalized?*

Yes

Please describe.*

Have you ever been in a partial or intensive care program?*

Yes

Please describe.*

Have you ever had genetic testing done?*

Yes

Please bring the results to your appointment.

Antidepressant Meds/Therapies

Prozac (fluoxetine)

Paxil (paroxetine)

Zoloft (sertraline)

Celexa (citalopram)

Lexapro (escitalopram)

Luvox (fluvoxamine)

Wellbutrin (buproprion)

Effexor (venlafaxine)

Cymbalta (duloxetine)

Pristiq (desvenlafaxine)

Remeron (mirtazapine)

Serzone (nefazodone)

Viibryd (vilazodone)

Trintellix (vortioxetine)

Elavil (amitriptyline)

Zurzavae (zuranolone)

Zulresso (brexanolone)

Auvelity (dextromethorphan and bupropion)

Sleep/Anxiety Meds/Therapies

Desyrel (trazodone)

Atarax (hydroxyzine)

Ambien (zolpidem)

Klonopin (clonazepam)

Ativan (lorazepam)

Xanax (alprazolam)

Inderal (propranolol)

BuSpar (buspirone)

Valium (diazepam)

Lunesta (eszopiclone)

Belsomra (suvorexant)

Restoril (temazepam)

Rozerem (ramelteon)

Silenor (doxepin)

Sonata (zaleplon)

Benadryl (Diphenhydramine)

Mood Stabilizer Meds/Therapies

Lamictal (lamotrigine)

Trileptal (oxcarbazepine)

Depakote (valproic acid)

Topamax (topiramate)

Neurontin (gabapentin)

Eskalith (lithium)

Lyrica (pregabalin)

Abilify (aripiprazole)

Geodon (ziprasidone)

Risperdal (risperidone)

Fanapt (iloperidone)

Invega (paliperidone)

Caplyta (lumateperone)

Zyprexa (olanzapine)

Seroquel (quetiapine)

Rexulti (brexpiprazole)

Saphris (asenapine)

Latuda (lurasidone)

Vraylar (cariprazine)

Haldol (haloperidol)

Long-acting Injectable (LAI)

ADHD Meds/Therapies

Ritalin, Concerta, Daytrana, Quillivant XR (methylphenidate)

Focalin (dexmethylphenidate)

Adderall (dextroamphetamine/amphetamine)

Vyvanse/Dexedrine (dextroamphetamine)

Strattera (atomoxetine)

Qelbree (viloxazine)

Catapress/Kapray (clonidine)

Tenex/Intuniv (guanfacine)

Bright Light TX

Vit D3

TMS

Spravato (or Ketamine)

Thyroid (T4)

ECT

Omega 3 fatty acid

CoQ10

Probiotics

N-Acetylcysteine (NAC)

Anti-inflammatories

Other Meds/Therapies

Do you drink alcohol?*

Never

Former

Current

How many times per week?*

How many drinks?*

Do you use nicotine?*

Never

Former

Current

What form?*

How much?*

Do you use any other substances?*

Never

Former

Current

Please describe.*

Do you exercise regularly?*

Never

Former

Current

What exercise?*

How often?*

Do you gamble?*

Never

Former

Current

In what form?*

Over the last 2 weeks, how often have you been bothered by the following symptoms:

Not at all
Several days
More than half of the days
Nearly every day

Little interest or pleasure in doing things*

0. Not at all

1. Several days

2. More than half of the days

3. Nearly every day

Feeling down, depressed, or hopeless*

0. Not at all

1. Several days

2. More than half of the days

3. Nearly every day

Trouble falling asleep, staying asleep, or sleeping too much*

0. Not at all

1. Several days

2. More than half of the days

3. Nearly every day

Feeling tired or having little energy*

0. Not at all

1. Several days

2. More than half of the days

3. Nearly every day

Poor appetite or overeating*

0. Not at all

1. Several days

2. More than half of the days

3. Nearly every day

Feeling bad about yourself, or that you are a failure to have let others down*

0. Not at all

1. Several days

2. More than half of the days

3. Nearly every day

Trouble concentrating on things*

0. Not at all

1. Several days

2. More than half of the days

3. Nearly every day

Moving or speaking so slowly that other people could have noticed, or being so fidgety or restless that you have been moving around a lot more than usual*

0. Not at all

1. Several days

2. More than half of the days

3. Nearly every day

Thoughts that you would be better off dead or of hurting yourself*

0. Not at all

1. Several days

2. More than half of the days

3. Nearly every day

If you checked off any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Has there ever been a period of time when you were not your usual self and

you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?

you were so irritable that you shouted at people or started fights or arguments?

you felt much more self-confident than usual?

you got much less sleep than usual and found that you didn't really miss it?

you were more talkative or spoke much faster than usual?

thoughts raced through your head or you couldn't slow your mind down

you were so easily distracted by things around you that you had trouble concentrating or staying on track?

you had much more energy than usual?

you were much more active or did many more things than usual?

you were much more social or outgoing than usual: for example, you telephone friends in the middle of the night?

you were much more interested in sex than usual?

you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

spending money got you or your family into trouble?

If you checked Yes to more than one of the above, have several of these ever happened during the same period of time?*

Yes

How much of a problem did any of these cause you (like being unable to work; having family, money, or legal troubles; and/or getting into arguments or fights)?

No problem

Minor problem

Moderate problem

Serious problem

Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?*

Yes

Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?*

Yes

I hereby give my informed consent for Psychiatric Services, P.C. regarding my treatment to speak with or send documentation to my primary care physician.*

Yes

N/A

Primary Care Physician Name*

Primary Care Physician Address*

I hereby give my informed consent for Psychiatric Services, P.C. regarding my treatment to speak with or send documentation to my therapist.*

Yes

N/A

Therapist Name*

Therapist Address*

At Psychiatric Services, PC, we are committed to treating and using protected health information about you responsibly. Below are listed ways in which your personal information may be used. We ask that you read the following carefully. Please use checkboxes to indicate your permission. Unless otherwise noted, this release will remain in effect until the patient’s treatment is completed. Telephone messages: At times, Psychiatric Services, PC, may need to contact you by phone. We also make appointment reminder calls. Please indicate how you prefer we leave messages for each type of message.

General message

On voicemail or answering machine

Via text message

With family member

Which family member(s)?*

Detailed message including medical details or test results

On voicemail or answering machine

Via text message

With family member

Which family member(s)?*

Please check the following for which you give permission

My Power of Attorney may need to be present at time of examination, may need to telephone or write Psychiatric Services, PC, for information regarding my health, appointments or billing.

If I have someone accompany me into the doctor's or therapist's office, I give permission for the doctor or therapist to discuss my case, test results, or any other health information in the person’s presence.

I give permission to Psychiatric Services, P.C. to allow someone other than myself to pick up my prescriptions as designated by me verbally at that time.

Consent to Release Information*

My records are protected under Federal Regulation 42 CFR, Confidentiality of Alcohol and Drug abuse and under the general laws of my state. They cannot be re-disclosed without my written consent, except as specially stated by law.

I am authorizing the release of confidential information which is to be used in conjunction with the professional services I am receiving.

This authorization shall remain in effect until otherwise withdrawn or canceled by me in writing. A copy of this authorization is as good as the original.

I understand and agree to the above.

Treatment Agreement Consent*

I understand that I am financially responsible for all charges incurred for the services received from the above providers, including deductible and copays and regardless of insurance coverage, at time of service.

I am responsible for charges that insurance denies for any reason. In the event of non-payment, Psychiatric Services reserves the right to refer to a collection agency.
It is my responsibility to check and be familiar with my mental health benefits, including precertifications.

I have been informed that my insurance company may request copies of my medical records be sent in order to make payment or authorize further visits. My signature below gives my permission to release this information and to send medical records when requested.

I must present any changes of address, guarantor status, employment and insurance coverage no later than the first visit after these changes

The effectiveness of treatment depends upon my commitment and follow through with appointments. If I do not give 24 hours notice of cancellation, I may be charged. Missing repeat appointments may result in termination of care.

No recording devices are to be used by me in session. Scribe services may record session for provider but recordings are immediately deleted.

Inappropriate behavior in the office or on the phone with anyone at Psychiatric Services, PC may result in termination.

I consent to the care and treatment for myself by Psychiatric Services, P.C. as well as the Credit Policy as outlined above.

Date*

Month

Day

Year