• New Patient Intake Form

    Patient Registration at Cornerstone Psychiatric Services, Inc.
  • Notice

    • Age limit: patients 18 years of age and older.
    • Our providers DO NOT prescribe or manage Suboxone (buprenorphine and naloxone) or Clozoril (clozapine).
    • Our practice does not accept cases related to: workers compensation, auto accident, personal injury, court order psychiatric evaluations or pre-surgical clearance evaluations.

     

  • This is the final step - STEP 4 - New Patient Registration Intake Form. With this online form you can upload documents such as your photo id, insurance card(s) (front and back side), most recent lab results, current complete medication list. So, if you have any of these documents, please have them available to upload on this online version.

    • Scroll to bottom of this page and click on CLICK TO START button to begin. 
    • Remember to click NEXT button at the bottom of each page until you get to the end of Page 7 where you will click the SUBMIT button to send your form electronically.
    • You will receive a confirmation once you submit at the end. If you do not receive confirmation then your form maybe missing some required fields. If you do not hear back from our office in two business days of your submission, please call our office. 

    IMPORTANT NOTE: Make sure you have dedicated time (approximately 20-30 minutes) to complete the form as you are not able to save and restart where you left off. Once you start then complete the form to the end with no interruptions. If you leave the form idle for more than 30 minutes, your session will time out.

    You must complete this form electronically and once you get to last page (page 7) you will click on SUBMIT button.

    We will NOT accept this electronic form if you print it out as this is not in the correct format.  If you don't want to provide this information electronically, then call our office for another option in completing your New Patient Registration Form. 

    Thank you. 

     Before you begin, please review the following documents:

    • HIPAA - Notice of Privacy
    • Patient Rights and Responsibilities
    • Cornerstone Psychiatric Office Policies

     

                                                                

  • Cornerstone Psychiatric Services, Inc.

    David Donahue, D.O

     David Fawks, APRN ◊ Smitha Ajesh, APRN  ◊  Lenice Haber, LCSW ◊ Nancy Stetter-Coblentz, LCSW

    1790 E Venice Ave. Ste. 204, Venice, FL 34292

    Phone: (941) 488-8884    Fax: (941) 488-5554

    www.cornerstonepsychiatric.com

  • PATIENT INFORMATION


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  • PATIENT STATUS


  • COMMUNICATING WITH YOU

  • You agree and acknowledge that email, calls, texts, voicemail and any form of messaging to your home, mobile, work or other contact will pertain to information regarding things like appointments, patient portal, test results, medication side effects and prescriptions. If you wish to extend communication regarding your specific medical treatment and share of information with others, we ask that you sign a Release of Information form. If this information should at any time need to be modified, please complete a new Patient Demographic Form and/or ROI form with your requested change(s). 

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  • REFERRAL and PCP INFORMATION

  • Please provide your Primary Care Provider (PCP) contact info:



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    Click on the Next button to proceed to page 2
  • Lab Choices


  • PHARMACY and PRESCRIPTION DRUG BENEFIT

    Tell us which local pharmacy and mail order pharmacy that you use to fill your prescriptions:



  • INSURANCE / FINANCIAL RESPONSIBILITY




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  • Secondary/Supplemental Insurance Payer:

    (complete this section only if you have a secondary payer or supplement plan) Important Notice: We do not accept Florida Medicaid, out-of-state Medicaid plans or any Medicaid HMO plans. Please upload copy of your secondary insurance card as well.

  • UPLOAD PHOTO ID and INSURANCE CARDS SECTION

    Please upload the following:

    1) Photo ID (Drivers License or Passport)

    2) Primary Insurance Card (front and back sides)

    3) Secondary or Supplemental Insurance Card (front and back sides)

    4) Prescription Drug Benefit Card (front and back sides)

    You can use your mobile device or iPad to take a front picture of your photo id, and front and back side pictures of each: Primary Insurance, Secondary/Supplemental Insurance and your Prescription Drug Benefit Card.  Upload all these pictures of your cards by clicking on UPLOAD ID and INSURANCE CARD(S) BUTTON below. 

    These items will need to be provided to us before we can schedule your appointment. We prefer you upload these items here with the upload feature. If you do not do this now, you have two other options:

    1) You can bring in your ID and cards personally into the office for us to scan.

    2) After completing this form, go to our website, www.cornerstonepsychiatric.com, and click on 'Patient Forms' and scroll down to 'Upload Documents' option.

  • Upload Photo ID and Insurance Card(s)
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  • INSURANCE ASSIGNMENT AND SELF PAY AGREEMENT

  • AUTHORIZATION TO RELEASE

  • I certify that I have insurance coverage with the primary insurance company, if applicable; and the secondary insurance payer, if applicable, listed above. I assign directly to “Cornerstone” Psychiatric Services, Inc. (including David Donahue, D.O., David Fawks, APRN, Smitha Ajesh, APRN, Lenice Haber, LCSW, Nancy Stetter-Coblentz, LCSW or any clinician with the Cornerstone group), all insurance payments, if any, otherwise payable to me for services rendered. I understand I am financially responsible for deductible, co-payments, co-insurance, missed appointment fees, non-covered charges, and any and all balances not covered under a contractual agreement between “Cornerstone” and my insurance or other third party payer. I authorize the use of my signature for all insurance submissions. I request that payment of authorized Medicare benefits and, if applicable, Medigap benefits, be made on my behalf to “Cornerstone” for any services furnished to me by that provider. If Self Pay, I understand it is my responsibility to pay for services rendered at time of visit. I understand and agree that “Cornerstone” may use my health care information to the above named insurance payer(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I understand that if an authorization is needed from my insurance plan, it is my responsibility to obtain such authorization and provide this to “Cornerstone”.

  • Signature of Patient, Parent or Personal Representative:

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  • PATIENT CONSENT FOR EVALUATION OR TREATMENT

  • CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

  • CONSENT FOR OFFICE POLICIES and PATIENT PORTAL POLICIES AND PROCEDURES

  • Consent to Evaluate/Treat: I voluntarily consent that I will participate in a mental health (e.g. psychological or psychiatric) evaluation and/or treatment by staff from Cornerstone Psychiatric Services, Inc. I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:

    • The benefits of the proposed treatment
    • Alternative treatment modes and services
    • Expected side effects from the treatment and/or the risks of side effects from medications (when applicable)

    The evaluation or treatment will be conducted by one or more of the following provider types: a psychotherapist, a psychologist, a psychiatric nurse practitioner (APRN/ARNP), a psychiatrist, a licensed clinical social worker, a licensed therapist or an individual supervised by any of the professionals listed. I understand that clinicians David Fawks, and Smitha Ajesh are APRN’s. Benefits to Evaluation/Treatment: Evaluation and treatment may be administered with psychological interviews, psychological assessment or testing, psychotherapy, medication management, as well as expectations regarding the length and frequency of treatment. It may be beneficial to me, as well as the referring professional, to understand the nature and cause of any difficulties affecting my daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Clients should be aware that the process of psychotherapy may bring about unpleasant memories, feelings, and sensations such as guilt, anxiety, anger, or sadness, especially in its initial phases. It is not uncommon for these feelings to have an impact on current relationships you may have. If this occurs, it is very important to address these issues in session. Usually these unpleasant sensations are short lived. Possible benefits to treatment include improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations.

    * This consent is knowingly and freely given. This consent will expire 7 years after my last encounter visit at Cornerstone Psychiatric.

    * I hereby give my consent for Cornerstone Psychiatric Services and their Business Associate’s (such as, but not limited to, medical billing company, EHR vendor, collection agency, automated appointment reminder vendor, dictation service, Prescription Drug Monitoring Program database, and electronic prescription vendor) to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO You can ask for a copy or download a copy from our website www.cornerstonepsychiatric.com of the Notice of Privacy Practices provided by Cornerstone Psychiatric Services which describes such uses and disclosure in detail. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Center of Medicare and Medicaid services, my Medigap insurer, and their agents any information needed to determine these benefits for related services.

    * I have the right to review the Notice of Privacy Practices prior to signing this consent. Cornerstone Psychiatric Services reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Officer at 1790 E Venice Ave. Ste 204, Venice, FL 34292. You can also pick up a copy in our office.

    * With this consent, Cornerstone Psychiatric Services may communicate to me in reference to any items that assist the practice in carrying out TPO, such as, but not limited to, appointment reminders, billing statements, insurance issues and any messages pertaining to my clinical care, including laboratory test results, among others by use of phone calls to my home, mobile or other alternative location and speak or leave a message; SMS/Text message, Email, postal delivery and/or by the Patient Portal.

    * It is further understood that all information given by the patient or family member to a treating clinician is confidential and will not be released, except under special circumstances, without patient consent or consent of legal guardian as described in details in the Notice of Privacy Practices. You can authorize us to release information relating to your treatment to another person, provider or company by signing a Release of Information (ROI) form provided by our office.

    By signing this form, I am consenting to allow Cornerstone Psychiatric Services to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Cornerstone Psychiatric Services may decline to provide treatment to me. I understand and agree with all the preceding information unless otherwise indicated in writing. I acknowledge that I have received or been offered to review a copy of the following documents: Cornerstone “Welcome Letter”, “Patient Rights and Responsibilities” , “Notice of Privacy Practices”, “Office Policies”, and “Patient Portal Policy and Procedures”. I agree and accept the terms of all these documents. Copies of these documents are available at your request in our office or by downloading from our website.

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  • HEALTH SCREENING INFORMATION


  • 1.) Chief Complaint:

  • Stressors:


  • 2.) Psychiatric History:

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  • 3.) Substance Abuse History

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  • #3a.) Complete the table below regarding the following substances:

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  • 3b.) Alcohol Use:

  • 3c.) Have you experienced any of the following withdrawal symptoms and on what substance(s)?

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  • Smoking Status:

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  • 4.) Medical History


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  • PAST PSYCHIATRIC ONLY MEDICATIONS YOU HAVE TRIED AND ARE NO LONGER TAKING:

    If you have NO past psychiatric medication trials, then type in the word NONE on the first line under the 'Name' column.

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  • COMPLETE LIST OF ALL CURRENT MEDICATIONS: (Use the table below or if you have a current list, please print off and attach with this form or download our Complete Med list form available on our website, www.cornerstonepsychiatric.com under Patient Forms.

    If you have no current medications that you are currently taking, then write the word "NONE" in the first row and in the first column Current Medications.

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  • Family History

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  • NUTRITIONAL ASSESSMENT:


  • Comments and Additional Information:

  • Additional Document Uploads:

    Please use these different upload document buttons below for lab results, medication list or Durable POA / Healthcare Surrogate documents.
  • Upload your most recent lab results
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  • Upload Medication List
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  • Upload Durable POA /Healthcare Proxy docs
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  • FOR WOMEN ONLY:

  • You have reached the end.

    Please click on Submit button when you are done.
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