Carencia New Patient Form

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. You should be 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 to ensure that we indeed 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* Some mobile devices have difficulty completing our forms for various reasons. If you have trouble, please use a desktop device.

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

Carencia does not review your answers right away, so if you are having thoughts of hurting yourself and are worried about your safety, please report to the nearest hospital or call 911.

Patient Information
First name *
Last Name *
DO you have a middle name that you would like to provide? *

Yes No
Middle Name *
Do You Have a Preferred or Nick Name? *

Yes No
Preferred Name *
Gender *
RACE *
Religion
Date of Birth *

Month Day Year
Age
Marital Status *
CARENCIA CURRENTLY DOES NOT ACCEPT PATIENTS UNDER THE AGE OF 14. IN ORDER TO PROCEED PLEASE PROVIDE A BRIEF EXPLANATION OF WHY YOU OR YOUR DEPENDENT WOULD STILL LIKE TO BE SEEN BY A CARENCIA PROVIDER. *
Current Date hidden

Month Day Year
Date
PLEASE TAKE or upload A PHOTO OF YOURSELF FOR YOUR PATIENT PROFILE *
Contact Information
Address *

Street Address

Street Address Line 2

City State Abbreviation

Zip Code
Phone Number *
is phone number mobile? *

Yes No
Email *
Referral Information
Referral Source *
Referral Phone Number
Guardian/Guarantor Information
Legal Guardian *
Relationship to Client *
Legal Guardian Phone Number *
Legal Guardian Email Address *
LEGAL GUARDIAN ADDRESS (IF different from Patient's Address)

Street Address

Street Address Line 2

City State Abbreviation

Zip Code
Is there a custody agreement in place for the patient to whom you are a legal guardian? *

Yes No
If yes, Please upload any related Legal custodian documentation *
Employment Information
Are you currently employed? *
Employer *
Position
Salary
Work Number
Insurance Information
Will you be using insurance? *
Primary Insurance *
Employer *
Member ID # *
payer id # *
Group # *
Provider Line Phone Number *
Provider Line Phone Number
Who is the Subscriber? *
subscriber Name *

First Name Last Name
Subscriber Address *

Street Address

Street Address Line 2

City State Abbreviation

Zip Code
Subscriber Employer *
Subscriber Date of Birth *

Month Day Year
RELATIONSHIP TO SUBSCRIBER *
PLEASE TAKE or upload A PHOTO OF YOUR INSURANCE CARD (FRONT) *
PLEASE TAKE or upload A PHOTO OF YOUR INSURANCE CARD (BACK) *
Secondary Insurance Information
Will you be using SECONDARY insurance? *
Secondary Insurance *
Employer *
Member ID # *
payer id # *
Group # *
Phone Number *
Provider Line Phone Number
Who is the Subscriber? *
SUBSCRIBER NAME *

First Name Last Name
SUBSCRIBER Address *

Street Address

Street Address Line 2

City State Abbreviation

Zip Code
Subscriber Employer
Subscriber Date of Birth *

Month Day Year
Relationship to Subscriber *
PLEASE TAKE or upload A PHOTO OF YOUR INSURANCE CARD (FRONT) *
PLEASE TAKE or upload A PHOTO OF YOUR INSURANCE CARD (Back) *
Financial Responsibilities
Is there another person or entity finically responsible for treatment? *
Name of responsible Party *
Company of Responsible Party
Address of responsible party *

Street Address

Street Address Line 2

City State Abbreviation

Zip Code
Email *
example@example.com
Phone Number *
Emergency Contact Information
First and Last Name *
Relationship *
Phone Number *
Mobile Number
email address *
Pharmacy
Pharmacy Name *
PHARMACY ADDRESS *

Street Address

Street Address Line 2

City State Abbreviation

Zip Code
Phone Number *
Phone Number
Fax Number
Fax Number

Medical History

Please list all the medications and supplements you currently take, including the dose, instructions, and the reason for taking.
ARE YOU CURRENTLY TAKING ANY MEDICATIONS AND/OR SUPPLEMENTS? *

Yes No
Current Medications/supplements *
DO YOU HAVE ANY DRUG ALLERGIES? *

Yes No
Drug Allergies *
HAVE YOU BEEN DIAGNOSED WITH A MEDICAL ILLNESS AND/OR HAVE MEDICAL CONDITIONS? *

Yes No
Medical Illnesses *

Acknowledgements
ACKNOWLEGEMENTS and Consents *

I have read and agree to Carencia’s Financial Agreement in it’s entirety.
Acknowledgements *

I have read and agree to Carenica's Consent to Treatment in its entirety.
*

I have read and agree to Carenica's Communication Agreement in its entirety.
*

I have read and agree to Carenica's Medication Consent Agreement in its entirety.
*

I have read and agree to Carenica's Appointment Agreement in its entirety.
*

I have read and agree to Carenica's Buprenorphine Treatment Agreement in its entirety.
*

I have read and agree to Carenica's Vivitrol Treatment Agreement in its entirety.
*

I have read and agree to Carenica's Privacy Practices in its entirety.
Signature *

Clear

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.
Authorization *

By submitting this form, I authorize Carencia, LLC. to charge my credit card in the future for any transactions deemed necessary by the provider. I confirm that I have read and agree to Carencia's Financial Consent Agreement in its entirety.
ACKNOWLEGEMENTS *

I understand that no-shows or cancellations within 24 hours of appointment time will still be charged to card on file.

My Products

New Patient $ 0.01

Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Signature *

Clear
Should be Empty:

	Morning	Afternoon	Evening	All Day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

	None (None at all)	Slight (Rare, Less than a day or two)	Mild (Several Days)	Moderate (More than half the days)	Severe (Nearly Every Day)
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Feeling more irritated, grouchy, or angry than usual?
Sleeping less than usual, but still have a lot of energy?
Starting more projects than usual or doing more risky things than usual?
Feeling nervous, anxious, frightened, worried, or on edge?
Feeling panic or being frightened?
Avoiding situations that make you anxious?
Unexplained aches and pains?
Feeling that your illnesses are not being taken seriously enough?
Thoughts of actually hurting yourself?
Hearing things other people couldn't hear such as voices even when no one was around?
Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
Problems with sleep that affect your sleep quality overall?
Problems with memory (e.g. learning new information) or location (e.g. finding your way home)?
Unpleasant thoughts urges, or images that repeatedly enter your mind?
Feeling driven to perform certain behaviors or mental acts over and over again?
Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
Not knowing who you really are or what you want out of life?
Not feeling close to other people or enjoying your relationships with them?
Drinking at least 4 drinks daily of any kind of alcohol in a single day?

Carencia New Patient Form

Patient Questionnaire

Appointment Preferences

Patient Information

Guardian/Guarantor Information

Employment Information

Insurance Information

Emergency Contact Information

Pharmacy

Symptom Questionnaire

Medical History

Acknowledgements

Financial Information