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. 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. While the form can be completed on a mobile device we do recommend using a computer with Google Chrome or Microsoft Edge or Safari (if using a MacOS device).

- Clear all browser cache/cookies/history

- 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.
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.

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?*

YesNo
Current Medications/supplements*
DO YOU HAVE ANY DRUG ALLERGIES?*

YesNo
Drug Allergies*
HAVE YOU BEEN DIAGNOSED WITH A MEDICAL ILLNESS AND/OR HAVE MEDICAL CONDITIONS?*

YesNo
Medical Illnesses*

Treatment Hstory
Do you have any history of psychiatric treatment including, but not limited to medications, therapy, or hospitalizations?*

YesNo
HAVE YOU TAKEN MEDICATIONS FOR Mental Health or Substance Use REASONS That You Are Not Currently Taking?*

YesNo
PREVIOUS MEDICATIONS*
HAVE YOU HAD PREVIOUS MENTAL HEALTH TREATMENT other than medication?*

YesNo
PREVIOUS MENTAL HEALTH TREATMENT*
HAVE YOU HAD ANY TREATMENTS OTHER THAN THERAPY OR MEDICINE SUCH AS TMS OR BIOFEEDBACK FOR MENTAL HEALTH OR SUBSTANCE USE RELATED REASONS?*

YesNo
OTHER TREATMENTS*

Substance Use History
DO YOU HAVE ANY CURRENT MISUSE, ABUSE, OR DEPENDENCE OF SUBSTANCES?*

YesNo
DO YOU HAVE ANY PREVIOUS MISUSE, ABUSE, OR DEPENDENCE OF SUBSTANCES?*

YesNo
Please List Substance History*
HAVE YOU HAD ANY TREATMENT FOR SUBSTANCE USE?*

YesNo
TREATMENT FOR SUBSTANCE USE*

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
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New Patient$0.01

Total $0.00
Credit Card Details
First Name Last Name
Credit Card Number
Security Code
Card Expiration
Patient Signature*

Clear
Guardian Signature*

Clear
Indvidual Completing Form 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

Service and Provider Preferences

Appointment Preferences

Patient Information

Guardian/Guarantor Information

Employment Information

Insurance Information

Emergency Contact Information

Pharmacy

Symptom Questionnaire

Medical History

Treatment Hstory

Substance Use History

Acknowledgements

Financial Information

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