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  • Carencia New Patient Form

  •  FROM THE CARENCIA TEAM

    THANK YOU FOR YOUR COURAGE

    We know that reaching out for help regarding your mental health is not easy. We hope you are proud of yourself for taking this step, and we're honored to be considered for your treatment. 

    In order for our team to serve you as efficiently and effectively as possible, we ask that you fill out this questionnaire so that we can ensure we have all needed information and we are the proper fit to serve your mental healthcare needs. All of our forms are secure and HIPAA compliant, so you can provide all requested information without concern.

    *Please Note* If having difficulty submitting the form, please use the steps below to troubleshoot the issues.

    - Clear all browser cache/cookies/history

    - Make sure your browser is up to date

    - Try private or incognito mode in the browser

    - Try a different browser or computer or mobile phone

    If you are having trouble with the form or have questions regarding the form, please contact us at welcome@carencia.com.

  • Service and Provider Preferences

    Carencia offers different services with multiple providers in different states
  • Patient Questionnaire

  • Carencia provides both therapy and psychiatric services, therefore, we want to make sure we ask you a few questions that might help us guide you either now or in the future.

     

    There are no right or wrong answers, these questions simply help the Carencia team determine appropriate next steps. Please answer all questions as honestly as possible.

  • *Please be aware, this requires an in-person visit to our practice

  • *Please be aware, this requires an in-person visit to our practice

  • *Please be aware, this requires an in-person visit to our practice

  • *Please be aware, this requires an in-person visit to our practice

  • *Please be aware, this requires an in-person visit to our practice

  • Appointment Preferences

    Carencia generally operates 8am-5pm timeframe but we can work with you to accommodate some individual scheduling needs.
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  • Patient Information

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  • Contact Information


  • Referral Information


  • Guardian/Guarantor Information

  • Employment Information

  • Insurance Information

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  • EXAMPLE OF BLUE CROSS BLUE SHIELD PPO WHICH WE ACCEPT, WE DO NOT ACCEPT HMO PLANS

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  • EXAMPLE OF CARVE-OUT PLAN WHICH WE DO NOT ACCEPT

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  • Secondary Insurance Information


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  • Financial Responsibilities


  • Emergency Contact Information

  • Pharmacy

  • Symptom Questionnaire

  • The questions below are about things that might have bothered you. For each question, check the box next to the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.


  • During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?

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  • Medical History

    Please list all the medications and supplements you currently take, including the dose, instructions, and the reason for taking.
  • Treatment Hstory

  • Substance Use History

  • Acknowledgements

  • Financial Information

  •  AN HONEST APPROACH TO BILLING & FEES


    Finances can be a subject that medical practices avoid discussing. At Carencia, our financial transparency is a point of pride. We know that the intersection of financial realities and empathy is complicated, logistically and emotionally, so we’ve chosen to address this dilemma directly.

    How Carencia Uses Your Financial Information:

    Your card will not be charged today. Carencia securely stores your encrypted payment information, and we will only charge your card on file in the event of a late cancellation or missed appointment. For more information regarding our policies, please refer to our financial agreement. If you do not see a charge on your card for a missed appointment or late cancellation, please expect a request for payment at your next visit.

    Carenica's Stance on Missed & Canceled Appointments:

    We understand that late cancels and missed appointments can occur for many reasons, but the way in which they impact us goes beyond economics. It also means we’ve missed an opportunity to assist another patient during that same time. It’s our sincere hope that you understand our perspective.

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