2022 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 Name Middle Name Last Name
Preferred Name
Date of Birth *

Month Day Year
Date
Age *
Social Security Number
Address *

Street Address

Street Address Line 2

City State / 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 *

Male Female N/A Other
Pronouns

He/Him She/Her They/Them Other
Sexual Orientation *
Relationship Status *
Employer or School/Grade *
Highest Level of Education *

Currently Enrolled in School Some High School Finished High School Some College Finished College Graduate Degree Other
Height *
Weight *
Emergency Contact
Name *

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

Street Address

Street Address Line 2

City State / 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? *

Yes No
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? *

Yes No
Primary Care Provider

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

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

Month Day Year
Date
Are you receiving medical treatment at this time? *

Yes No
Current Health Concerns
(ie: hypertension, thyroid disease, diabetes, heart disease, kidney or liver problems)
History of Serious Accidents *

Yes No
History of Serious Accidents *
(ie: head trauma/concussions, car accidents)
History of Surgery *

Yes No
Surgical History *
Include Surgery, When, and Medical Provider
Are you currently taking any prescribed or over the counter medications, including supplements? *

Yes No
Medications (include name and dosage) *
Do you have any allergies? *

Yes No
List Allergies and Reaction *
(ie: Amoxicillin-rash)
Women's Health

(Skip for Males)
Date of Last Menstrual Cycle

Month Day Year
Date
Currently Pregnant

Yes No Unsure
Prior Number of Pregnancies
Currently Breastfeeding

Yes No
Current age (in months) of child being breastfed
Current Form of Birth Control
Family History
Any family history of medical diagnosis (excluding psychiatric diagnosis) *

Yes No
Details of Family Medical History *
(ie: Dad-diabetes, Mom- hypertension)
Any family history of psychiatric diagnosis (including substance abuse) *

Yes No
Details of Family Psychiatric History (including substance abuse) *
(ie: Grandmother- depression, Uncle-alcoholism)
Psychiatric History
Any history of psychiatric diagnosis *

Yes No
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 *

Yes No
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 Name Last Name
Phone Number
Please enter a valid phone number.
Any prior psychiatric hospitalizations? *

Yes No
Details of any prior psychiatric hospitalizations *
(ie: Novant Health Inpatient, 4 days in 2018 due to depression)
Any prior eating disorder treatment? *

Yes No
Details of any prior eating disorder treatment *
(ie: Intensive outpatient treatment at Atrium for six weeks in 2015)
Any history of suicide attempts *

Yes No
Details of suicide attempt(s) *
(When, by what means, did you seek medical treatment afterwards?)
Any history of self injury *

Yes No
Details of self injury *
(When, where at, by what means?)
Any history of inpatient psychiatric hospitalizations *

Yes No
Details of inpatient psychiatric hospitalizations *
(When, where at, by what means?)
Substance Abuse
Do you drink alcohol *

Yes No In 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? *

Yes No Unsure
Please Explain:
Have you ever sought substance abuse treatment? *

Yes No Considering
Do you have a history of withdrawal symptoms, such as seizures? *

Yes No
Please Explain:
Social History
Who lives in the home?
Do you feel safe at home? *

Yes No
Do you exercise on a regular basis? *

Yes No
Type of Exercise
Times Per Week
Do you have sleep difficulties? *

Yes No
Average Hours of Sleep Per Night
Quality of Sleep
Problems with Sleep (select as applicable)

Difficulty falling asleep Difficulty maintaining sleep Early morning awakening Fitful/Not restful Other
Do you use a CPAP consistently? *

Yes No
Do you follow a specific diet? (vegan, gluten free, etc) *

No Other
Recent weight change
Recent appetite change
Do you have access to firearms? *

Yes No
Please elaborate on access to firearms
Do you have a concealed carry permit? *

Yes No
Do you have any historical or pending legal issues? *

Yes No
Please elaborate on legal issues
Do you have any current or historical abuse or trauma? *

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

No Problems Lack of energy unexplained weight gain or weight loss loss of appetite Fever night sweats pain in jaws when eating scalp tenderness prior diagnoses of cancer
Ears, Nose, Mouth & Throat: *

No Problems ringing in ears Difficulty with hearing difficulty swallowing sinus problem mouth sores runny nose loose teeth post-nasal drip ear pain nose bleeds sore throat facial pain or numbness
Cardiac: *

No Problems racing heart Irregular heartbeat chest pains swelling of feet or legs pain in legs with walking structural abnormalities history of abnormal EKG.
Resp. (Lungs & Breathing): *

No Problems sputum production Shortness of breath oxygen at home prolonged cough coughing up blood wheezing abnormal chest x -ray
GI (Stomach & Intestines): *

No Problems diarrhea Heartburn abdominal pain constipation difficulty swallowing intolerance to certain foods nausea, vomiting blood in stools unexplained change in bowel habits incontinence
Kidney & Bladder: *

No Problems frequent urination Painful urination urinary urgency urinary urgency prostate problems bladder problems
Skin, Hair & Breast: *

No Problems change in existing skin lesion Persistent rash hair loss or increase itching breast changes new skin lesion nipple discharge.
Neurologic (Brain & Nerves): *

No Problems change in sensation frequent headaches problems with walking or balance double vision dizziness weakness tremor loss of consciousness uncontrolled motions episodes of vision loss
Endocrinologic (Glands): *

No Problems sexual dysfunction intolerance to heat or cold frequent hunger/urination/thirst changes in sex drive menstrual irregularities
Hematologic (Blood/Lymph): *

No Problems easy bleeding easy brusing anemia, abnormal blood tests leukemia unexplained swollen areas
Allergic/Immunologic: *

No Problems itching seasonal allergies frequent infections hay fever symptoms exposure 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 Name Last Name
Date *

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

Clear

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 Name Last Name
Date *

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

Clear

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 Name Last Name
DOB: *

Month Day Year
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) *

Clear
Date *

Month Day Year
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.

Payment Method
Patient Name *

First Name Last Name
Card Holder Name: *

First Name Last Name
Relationship: *
Credit Card Number:   Number*

Expiration Date:   MM/YY*

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

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

Clear
Date *

Month Day Year
Date

	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 things ty
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 things eness
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 Right and Responsibilities/Consent for Treatment

Privacy Policies

Waiver of Electronic Mail, Voice & SMS Message Confidentiality Release

Payment Method

Office Policies

Patient Symptom Self Report Scales

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?