New Patient Interest Interview

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I am completing this form for:* This field is required.
Myself
My Child
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Your Name* This field is required.
First Name
Last Name
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Now
Date
Month
Day
Year
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Date of Birth* This field is required.MM/DD/YYYY
Date
Month
Day
Year
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Filler Age
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Mailing Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Cell Phone Number* This field is required.
Please enter a valid phone number.
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Home Phone Number* This field is required.
Please enter a valid phone number.
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Email* This field is required.
example@example.com
Confirm Email
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Your Biological Sex* This field is required.
Male
Female
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Child's Name* This field is required.
First Name
Last Name
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Child's Date of Birth* This field is required.
Enter Date (MM), Day (DD), and Year (YYYY)
Month
Day
Year
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Age of Child
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Child's Biological Sex* This field is required.
Male
Female
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Were you referred for Spravato® Treatment?* This field is required.
YESNO
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We are in network with the plans below. Please select the one you will be using.* This field is required.
BlueCross BlueShield
CommunityCare
EDS HealthChoice
UnitedHealthcare
Self-pay
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Insurance ID* This field is required.
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Insurance Group Number* This field is required.
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Insurance Subscriber* This field is required.Who is the policy registered to?
I am the subscriber
My child is the subscriber (Medicaid)
Someone else is the subscriber
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Insurance Subscriber's Name* This field is required.
First Name
Last Name
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Insurance Subscriber's Date of Birth* This field is required.
Date
Year
Month
Day
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For what reason (s) are you requesting treatment?* This field is required.
ADD or ADHD
Anxiety
Autism
Bipolar Disorder
Depression
Insomnia (Trouble with sleep)
Personality Disorder
Panic Attacks
OCD (Obsessive Compulsive Disorder)
PTSD
Other
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For what reason(s) are you requesting this appointment?
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Has there been a previous diagnosis of ADD or ADHD?* This field is required.
YESNO
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Has ADD/ADHD testing been completed?* This field is required.
YESNO
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Age when ADD/ADHD testing was completed* This field is required.
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Who performed the ADD/ADHD testing* This field is required.
Clinical Psychologist
Pediatrician
Primary Care Provider
Psychiatrist
Other
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Is there a history of OUTPATIENT mental health care?* This field is required.Eg: Psychiatrist, therapist, psychologist
Yes
No
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Enter Facility Name(s), dates (approximate is ok), and reason for discontinuation.* This field is required.
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Has there been a previous diagnosis of a psychiatric illness?* This field is required.
Yes
No
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Please list previous psychiatric diagnoses* This field is required.Enter NA if this does not apply to you.
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Has a personality disorder been diagnosed ?* This field is required.
Yes
No
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Please select all personality disorders that apply* This field is required.
Antisocial Personality
Avoidant Personality
Borderline Personality
Dependent Personality
Histrionic Personality
Narcissistic Personality
Obsessive-Compulsive Personality
Paranoid Personality
Schizotypal Personality
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Is there a history of psychiatric hospitalization?* This field is required.
Yes
No
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List previous psychiatric hospitalization(s) with dates* This field is required.
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Are there any current medical problems?* This field is required.
Yes
No
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Please list current medical problems* This field is required.
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Please list current medications* This field is required.
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Please list previous medications which have been tried and failed* This field is required.A failed medication is one that caused a negative, unacceptable side effect, or one that did not work effectively.
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Is there current substance use?* This field is required.
YESNO
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Please select all substances that apply.* This field is required.
Prescription Medications (other than your own)
Street Drugs (Illegal Substances)
Other
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Please describe the substance use patterns.* This field is required.Enter details about your substance use including frequency.
Enter whether you engage daily, weekly, occasionally.
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Alcohol consumption?* This field is required.
Yes
No
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How often has the consumption of 5 or more alcoholic beverages in a single sitting occurred during the past 30 days?* This field is required.
Never
Occasionally
Frequently
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Never
Row 0, Column 0
Occasionally
Row 0, Column 1
Frequently
Row 0, Column 2
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Is marijuana (THC) being used?* This field is required.Answering YES will not automatically disqualify you from becoming a patient.
Yes
No
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Marijuana (THC) use frequency.* This field is required.
Less than monthly
Monthly
Weekly
2-3 times a week
4-6 times a week
Daily
Select one
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Select one
Less than monthly
Row 0, Column 0
Monthly
Row 0, Column 1
Weekly
Row 0, Column 2
2-3 times a week
Row 0, Column 3
4-6 times a week
Row 0, Column 4
Daily
Row 0, Column 5
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I understand that Tulsa Family Psychiatry & Wellness will review medication history via the Oklahoma Prescription Monitoring Program and via SureScripts.* This field is required.
Yes, I consent
No, I do not consent
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I understand that providers at Tulsa Family Psychiatry do not recommend ongoing treatment with benzodiazepines.* This field is required.Benzodiazepines include: Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam, (Valium) Lorazepam, and several others.
Yes, I understand
No, I do not understand
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Benzodiazepines are a class of medications primarily used for treating anxiety, insomnia, seizures, muscle spasms, and certain other conditions. While effective for short-term use, long-term use of benzodiazepines is associated with a variety of risks:

Dependence and Withdrawal: With prolonged use, there's a risk of physical and psychological dependence. Withdrawal symptoms can be severe and include increased anxiety, insomnia, muscle twitching, tremors, and in severe cases, seizures.

Cognitive Effects: Long-term use can lead to memory issues, attention deficits, and slowed cognitive processing. Some of these effects might be reversible upon discontinuation, but not always.

Fall Risk: Especially in older adults, benzodiazepines can increase the risk of falls, leading to fractures or other injuries due to their sedative effects.

Respiratory Depression: There's an increased risk of respiratory depression, especially if combined with other central nervous system depressants like opioids or alcohol.

Tolerance: Over time, users may need increasing doses to achieve the same therapeutic effect, which can escalate the other risks associated with these drugs.

Mental Health Effects: Some people might experience paradoxical reactions, like increased anxiety, agitation, aggression, hallucinations, or other behavioral changes.

Drug Interactions: Benzodiazepines can interact with many other medications, enhancing sedative effects and potentially leading to overdose.

Potential for Overdose: Especially when taken with other sedatives or alcohol, there's a risk of overdose, which can be fatal.

Rebound Symptoms: Discontinuing the drug can lead to a return of the symptoms it was treating, often more severe than before.

Potential Link to Dementia: Some research suggests a potential link between long-term benzodiazepine use and an increased risk of dementia, though the evidence is not definitive.

Birth Defects: If taken during pregnancy, some benzodiazepines are associated with a risk of birth defects or behavioral issues in the child.
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How did you hear about us?* This field is required.
Google
Therapist
Pediatrician
Other healthcare provider
Friend or Family Member
Other
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Form submitter's signature* This field is required.
Clear
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