2023 New Patient Information

New Patient Information

Please complete at least 24 hours prior to your new patient evaluation.
Patient Information
Legal Name of Patient*

First NameMiddle NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Age*
Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Phone Number*
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Email*
example@example.com
Referral Source
(ie Google, Facebook, Friend, Therapist)
Race:
Gender*

MaleFemaleN/AOther
Pronouns

He/HimShe/HerThey/ThemOther
Sexual Orientation*
Relationship Status*
Employer or School/Grade*
Highest Level of Education*

Currently Enrolled in SchoolSome High SchoolFinished High SchoolSome CollegeFinished CollegeGraduate DegreeOther
Emergency Contact
Name*

First NameLast Name
Relationship to Patient*
Phone Number*
Please enter a valid phone number.
Preferred Pharmacy
Pharmacy*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Insurance Information

To be used to aid with prescription issues
Do you have prescription insurance?*

YesNo
Insurance Provider
ID Number
Group Number
BIN
PCN
Current Concerns
What is your greatest concern that has caused you to seek evaluation and treatment?*
What have you already tried to help these problems?
What is your biggest goal in seeking psychiatric care?*
Medical History
Do you have a primary care provider?*

YesNo
Primary Care Provider

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Last Physical Exam

MonthDayYear
Date
Are you receiving medical treatment at this time?*

YesNo
Current Health Concerns
(ie: hypertension, thyroid disease, diabetes, heart disease, kidney or liver problems)
History of Serious Accidents*

YesNo
History of Serious Accidents*
(ie: head trauma/concussions, car accidents)
History of Surgery*

YesNo
Surgical History*
Include Surgery, When, and Medical Provider
Are you currently taking any prescribed or over the counter medications, including supplements?*

YesNo
Medications (include name and dosage)*
Do you have any allergies?*

YesNo
List Allergies and Reaction*
(ie: Amoxicillin-rash)
Women's Health

(Skip for Males)
Date of Last Menstrual Cycle

MonthDayYear
Date
Currently Pregnant

YesNoUnsure
Prior Number of Pregnancies
Currently Breastfeeding

YesNo
Current age (in months) of child being breastfed
Current Form of Birth Control
Family History
Any family history of medical diagnosis (excluding psychiatric diagnosis)*

YesNo
Details of Family Medical History*
(ie: Dad-diabetes, Mom- hypertension)
Any family history of psychiatric diagnosis (including substance abuse)*

YesNo
Details of Family Psychiatric History (including substance abuse)*
(ie: Grandmother- depression, Uncle-alcoholism)
Psychiatric History
Any history of psychiatric diagnosis*

YesNo
What psychiatric diagnosis? By whom and when?*
(ie: depression by primary care provider in 2006, bipolar disorder by psychiatry in 2012)
Any history of psychiatric medications*

YesNo
What psychiatric medications have you previously been prescribed? Include name, dose, dates, and the provider as you're able to recall.*
Therapy Status*
Current Therapist, if applicable

First NameLast Name
Phone Number
Please enter a valid phone number.
Any prior psychiatric hospitalizations?*

YesNo
Details of any prior psychiatric hospitalizations*
(ie: Novant Health Inpatient, 4 days in 2018 due to depression)
Any prior eating disorder treatment?*

YesNo
Details of any prior eating disorder treatment*
(ie: Intensive outpatient treatment at Atrium for six weeks in 2015)
Any history of suicide attempts*

YesNo
Details of suicide attempt(s)*
(When, by what means, did you seek medical treatment afterwards?)
Any history of self injury*

YesNo
Details of self injury*
(When, where at, by what means?)
Any history of inpatient psychiatric hospitalizations*

YesNo
Details of inpatient psychiatric hospitalizations*
(When, where at, by what means?)
Substance Abuse
Do you drink alcohol*

YesNoIn recovery
Drinks per week
Substance History

No history of substance use

Are you or family/friends concerned with your use of any substances at this time?*

YesNoUnsure
Please Explain:
Have you ever sought substance abuse treatment?*

YesNoConsidering
Do you have a history of withdrawal symptoms, such as seizures?*

YesNo
Please Explain:
Social History
Who lives in the home?
Do you feel safe at home?*

YesNo
Do you exercise on a regular basis?*

YesNo
Type of Exercise
Times Per Week
Do you have sleep difficulties?*

YesNo
Average Hours of Sleep Per Night
Quality of Sleep
Problems with Sleep (select as applicable)

Difficulty falling asleepDifficulty maintaining sleepEarly morning awakeningFitful/Not restfulOther
Do you use a CPAP consistently?*

YesNo
Do you follow a specific diet? (vegan, gluten free, etc)*

NoOther
Recent weight change
Recent appetite change
Do you have access to firearms?*

YesNo
Please elaborate on access to firearms
Do you have a concealed carry permit?*

YesNo
Do you have any historical or pending legal issues?*

YesNo
Please elaborate on legal issues
Do you have any current or historical abuse or trauma?*

YesNo
Please elaborate on abuse/trauma
(physical, sexual, verbal/emotional)
Anything else you would like your clinician to know
Height*
Weight*
REVIEW OF SYSTEMS: Check "No Problems" or circle applicable issues or explain any that may not be listed.
Const. (Health in General):*

No ProblemsLack of energyunexplained weight gain or weight lossloss of appetiteFevernight sweatspain in jaws when eatingscalp tendernessprior diagnoses of cancer
Ears, Nose, Mouth & Throat:*

No Problemsringing in earsDifficulty with hearingdifficulty swallowingsinus problemmouth soresrunny noseloose teethpost-nasal dripear painnose bleedssore throatfacial pain or numbness
Cardiac:*

No Problemsracing heartIrregular heartbeatchest painsswelling of feet or legspain in legs with walkingstructural abnormalitieshistory of abnormal EKG.
Resp. (Lungs & Breathing):*

No Problemssputum productionShortness of breathoxygen at homeprolonged coughcoughing up bloodwheezingabnormal chest x -ray
GI (Stomach & Intestines):*

No ProblemsdiarrheaHeartburnabdominal painconstipationdifficulty swallowingintolerance to certain foodsnausea,vomitingblood in stoolsunexplained change in bowel habitsincontinence
Kidney & Bladder:*

No Problemsfrequent urinationPainful urinationurinary urgencyurinary urgencyprostate problemsbladder problems
Skin, Hair & Breast:*

No Problemschange in existing skin lesionPersistent rashhair loss or increaseitchingbreast changesnew skin lesionnipple discharge.
Neurologic (Brain & Nerves):*

No Problemschange in sensationfrequent headachesproblems with walking or balancedouble visiondizzinessweaknesstremorloss of consciousnessuncontrolled motionsepisodes of vision loss
Endocrinologic (Glands):*

No Problemssexual dysfunctionintolerance to heat or coldfrequent hunger/urination/thirstchanges in sex drivemenstrual irregularities
Hematologic (Blood/Lymph):*

No Problemseasy bleedingeasy brusinganemia, abnormal blood testsleukemiaunexplained swollen areas
Allergic/Immunologic:*

No Problemsitchingseasonal allergiesfrequent infectionshay fever symptomsexposure to HIV

Patient Right and Responsibilities/Consent for Treatment
This is to help you understand your rights and responsibilities and the level of cooperation that we need from you in order to help you realize the highest level of mental and emotional health of which you are uniquely capable. Our desire is to form a partnership with you regarding your mental health. Your assistance is crucial and the interest and commitment that you bring to this partnership are essential to attaining significant improvement or resolution to your mental health concerns.

YOUR RIGHTS

You are assured the following rights:

-The right to be treated with dignity and respect

-The right to treatment including access to medical care and habilitation, regardless of your race, religion, gender, ethnicity, age, or sexual orientation.

-The right to have your treatment and other patient information kept private.

-The right to know about all your treatment choices, regardless of the cost of those treatment choices, and to participate in the choice of treatment.

-The right to consent or to refuse treatment,consent can be withdrawn at any time.

-The right to obtain a copy of your treatment plan by completing a release form.

-The right to contact Disability Rights of North Carolina at 919-856-2195.

YOUR RESPONSIBILITIES

In order to provide you with the best care, your commitment to your treatment and recover is essential. We require that patients’ understand their role and responsibilities in their care:

-You have the responsibility to give your provider the information needed so that we can delver the best possible care.

-You have the responsibility to let your treating provider know if or when the treatment plan no longer works for you.

-You have the responsibility to follow your medication plan. You must tell your treating provider about any medication changes, including medications prescribed for you by other healthcare professionals.

-You have the responsibility to keep your scheduled appointments.

-You have the responsibility to ask your treating provider any questions you may have about your care, so that you can better understand your care and the role you play in your care.

-You have the responsibility to follow your treatment plan and instructions for your care, once that care has been agreed upon by you and your treating provider.

By signing below, you acknowledge that you fully understand your rights and responsibilities, and that you consent for care and treatment by Carolina Complete Psychiatry, PLLC.

I have read and fully understand my rights and responsibilities in my partnership with Carolina Complete Psychiatry, PLLC in providing for my care, and agree to adhere to them, and acknowledge that I have received a copy of this statement. Further, I hereby consent to outpatient treatment and give permission for the clinician to provide the services deemed necessary or advisable in the diagnosis and treatment of the patient. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made as to the result of treatment received by Carolina Complete Psychiatry, PLLC. I understand that the patient has the right to without consent to any medical service that is deemed necessary or advisable by the clinician. My signature below indicates my understanding and approval of the above.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature of Patient/Legal Guardian (and relationship if patient is a minor)*

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Privacy Policies
This notice describes how medical information about you may be used and disclosed and your access to it. Protected health information about you is obtained as a record of your visits or contacts with Carolina Complete Psychiatry, PLLC for healthcare services. Specifically, PROTECTED HEALTH INFORMATION is information about you, including demographic information (name, address, age, etc.) that may identify you and may relate to your past, present and/or future physical or mental health condition(s) and related healthcare services. Carolina Complete Psychiatry, PLLC is required to follow specific rules for maintaining the confidentiality of your protected health information, the use of your information and how providers disclose or share this information to/with other healthcare professionals involved in your care and treatment. All employees, interns, students may have access to your records, while working with Carolina Complete Psychiatry. This Policy describes your rights to access and control your protected health information. It also describes how we follow those rules in the use and disclosure of your protected health information for the purposes of providing treatment, obtaining payment for the services you receive, managing our healthcare operations and for other purposes permitted/required by law.
YOUR RIGHTS UNDER THE PRIVACY RULE:
The following is a statement of your rights under the Privacy Rule in reference to your protected health information. Please feel free to discuss any questions/concerns with the staff.
YOUR RIGHTS TO A COPY OF PRIVACY POLICIES
We are required to follow the terms of this notice. We reserve the right to change the terms of our notice at any time. If needed, new versions of this notice will be effective for all protected health information that we maintain. Upon request, you will be provided with a revised Notice of Privacy Policies.
YOUR RIGHTS TO AUTHORIZE OTHER USE AND DISCLOSURE
This means that you have the right to authorize or deny authorization for any other use/disclosure of protected health information not specified in this notice. You may revoke an authorization at any time except to the extent that Carolina Complete Psychiatry, PLCC has taken an action in reliance on the use or disclosure indicated in the
authorization. Any revocation of authorization to use or disclose protected health information must be presented in writing.
YOUR RIGHTS TO DESIGNATE A PERSONAL REPRESENTATIVE
This means that you may designate a person who then has the delegated authority to consent to or authorize the use or disclosure of your protected health information. Any notice of revocation of authorization/designation of a previously named personal representative must be presented in writing.
YOUR RIGHTS TO YOUR PROTECTED HEALTH INFORMATION
This means that you may inspect and obtain a copy of protected health information about you that is contained in your patient record. Under certain circumstances, we may deny your request or redact information. Any requests for copies of your protected health information must be made in writing.
YOUR RIGHTS TO REQUEST A RESTRICTION OF YOUR PROTECTED HEALTH INFORMATION
This means that you may request, in writing, that we not disclose any part of your protected health information for the purposes of treatment, payment for service you have received, or healthcare operations. You may also request that any part of your protected health information be restricted from disclosure to others who may be involved in your care or for notification purposes as described in this Notice of Privacy Policies. Under certain circumstances, we may deny your request for restriction. All requests for restriction of your protected health information must be made in writing.
YOUR RIGHTS TO REQUEST YOUR PROTECTED HEALTH INFORMATION AMENDED
This means that you may request an amendment of your protected health information for as long as we maintain the information. Under certain circumstances, we may deny your request for an amendment. All requests for amendment to your protected health information must be made in writing.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for Carolina Complete Psychiatry, PLLC. A copy of this signed, dated document shall be as effective as the original. A current copy of the privacy policy may be found at www.ccpsychiatry.com.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature of Patient/Legal Guardian (and relationship if patient is a minor)*

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Payment Method
Please note: You must inform the office if there have been ANY changes to your credit card information. Failure to inform the office of such changes or a declined credit card transaction will result in a $25.00 charge to your account.

By signing below, you agree to, approve, and understand all of the following:

Carolina Complete Psychiatry, PLLC, reserves the right to charge the credit card on file, at any time for service provided by the company.

If your account at Carolina Complete Psychiatry, PLLC carries an outstanding balance for more than 30 days, we may charge the card for the outstanding amount without giving prior notice.

You have the right to request an invoice/statement at any time.

Carolina Complete Psychiatry, LLPC. will not be held liable for any fraudulent charges made to the credit card account.

If you are not the cardholder of the credit card, you agree to take full responsibility for any charges made by Carolina Complete Psychiatry to the card you have provided.
Name*

First NameLast Name
Signature of Patient/Legal Guardian (and relationship if patient is a minor)*

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Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Card Holder Name:*

First NameLast Name
Relationship:*
WE DO NOT CARRY PATIENT BALANCES.
ALL FEES ARE DUE AT THE TIME OF SERVICE.
A VALID CREDIT CARD OR DEBIT CARD IS REQUIRED BY ALL PATIENTS.
- In the event of a missed appointment without proper 24 hour cancellation, the following card will be charged for the full fee of the appointment
- In the event of a late arrival greater than 10 minutes or a cancellation less than 24 hours, the following card will be charged $100
Credit Card Number:   Number*

Expiration Date:   MM/YY*

CVV:   3 Digit cide*   Zip code:   Number*
Card Holder Signature:*

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Waiver of Electronic Mail, Voice & SMS Message Confidentiality Release
Carolina Complete Psychiatry, PLLC may contact me at the following phone numbers or email address regarding my appointments, treatment, and information about my health. Messages may be left unless otherwise noted.

By providing my email address below and signing, I understand that I give Carolina Complete Psychiatry permission SMS (text message), call or e-mail me on the account given. Furthermore, I understand that e-mail and text messages is not a HIPAA compliant form of communication, nor is information protected in any way other than basic passwords. I waive any and all liability for Carolina Complete Psychiatry, PLLC in the event of information disclosure that resulted from the use of e-mail, voicemail and/or text messages.
Name*

First NameLast Name
DOB:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Signature of Patient/Legal Guardian (and relationship if patient is a minor)*

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Date*

MonthDayYear
Date
If you would prefer NO communication by email, please click below.
Lastly, you are invited to use Patient Fusion, an electronic communication portal that is encrypted and HIPAA complaint. This will allow you to communicate with your provider, as well as see upcoming appointments, medications, and recent lab work results. Please ask the office for an invitation code if you do not want an invitation to be sent to you via email.

	Use	Average Amount Used	Age of First Use	Last Use	History of Treatment
Tobacco
Vape/E-cig
Cannabis
Delta 8/THC
Cocaine
Opiates/Heroin
Pills
Other

	Yes	No
.. you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got in trouble?
.. you were so irritable that you shouted at people or started fights or arguments?
...you felt much more self-confident than usual?
...you got much less sleep than usual and found that you didn’t really miss it
...you were more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
...you had more energy than usual?
...you were more active or did many more things than usual?
...you were much more social or outgoing than usual, for example you telephoned friends in the middle of the night?
....you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
...spending money got you or your family in trouble?

	0	1	2	3
Little interest or pleasure in doing thingsty
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching TV
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way

	0	1	2	3
feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different thingseness
Trouble Relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

	Yes	No
Have any of your closest relationships been troubled by a lot of arguments or repeated breakups?
Have you deliberately hurt yourself physically (e.g., punched yourself, cut yourself, burned yourself)? How about made a suicide attempt?
Have you had at least two other problems with impulsivity (e.g., eating binges and spending sprees, drinking too much and verbal outbursts)?
Have you been extremely moody?
Have you felt very angry a lot of the time? How about often acted in an angry or sarcastic manner?
Have you often been distrustful of other people?
Have you frequently felt unreal or as if things around you were unreal?
Have you chronically felt empty?
Have you often felt that you had no idea of who you are or that you have no identity?
Have you made desperate efforts to avoid feeling abandoned or being abandoned (e.g., repeatedly called someone to reassure yourself that he or she still cared, begged them not to leave you, clung to them physically)?

New Patient Information

Patient Information

Emergency Contact

Preferred Pharmacy

Insurance Information

Current Concerns

Medical History

Women's Health

Family History

Psychiatric History

Substance Abuse

Social History

REVIEW OF SYSTEMS: Check "No Problems" or circle applicable issues or explain any that may not be listed.

Patient Symptom Self Report Scales

Patient Right and Responsibilities/Consent for Treatment

Privacy Policies

Payment Method

Waiver of Electronic Mail, Voice & SMS Message Confidentiality Release

Office Policies

Release of Information

	Never	Rarely	Sometimes	Often	Very Often
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?