Psychiatric Medication Management New Client Intake Form

Psychiatric - Medication Management New Client Intake Form

Please fill in the form below. Note that this form and insurance information must be provided within three days after scheduling the appointment or the appointment will be given away.
Today's Date

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Date
Client Legal Name*

First NameMiddle NameLast NameSuffix
Photo of Client

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E-mail*
(Pattison Professional Counseling and Mediation Center offers paperless patient statements via email. Additionally, you will receive a monthly newsletter providing you with interesting articles and informative information pertaining to health and wellness. You may opt-out of receiving the newsletter at any time.)
Client's / Patient's Social Security Number*
Please enter the client's/patient's social security number only
Client's Date of Birth*

MonthDayYear
Client Sex*

MaleFemale
Mobile Phone Number*
Home Phone Number
Work Phone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Client's Marital Status*
Please select one of the options
If married, how long have you been married?
If you have children, please list the number of children and ages
If employed, where are you employed and how many years?
Enter your company's name and # of years employed
Is your condition related to:
Responsible Party Information (if client is a minor, please indicate parent information):
Name of Responsible Party

First NameLast Name
Relationship to the Client
Address if Different From Client's Address Listed Above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Home Number
Work Number
Responsible party's social security number
Please enter the social security number of the responsible party
Date of Birth

MonthDayYear
Date of your upcoming appointment with PPCMC

MonthDayYear
Date
Which provider will you be seeing?*
Which office will you be seen in?*
Thank you for choosing Pattison Professional Counseling and Mediation Center. We are interested in knowing how we were selected to serve you.
How were you referred to us?*
Please choose one option from the list.
If you were referred by a doctor or other therapist, please enter their name
Input the name of the professional, if applicable
Terms & Conditions for Treatment*

Agreement for Controlled Substances and Prescriptions

Please read this agreement in its entirety before signing.
The use of controlled medications may cause addiction and is only one part of the treatment for your condition. The goal of medicine is to work alongside therapy to treat your diagnosed conditions.

I have been told that:

1. If I drink alcohol or use street drugs, I may not be able to think clearly and I could become sleepy and risk personal injury.

2. I may get addicted to this medicine.

3. If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of addiction.

4. If I need to stop this medicine, I must do it slowly or I may get very sick.

I agree to the following:

I am responsible for my medicines. I will not share, sell, or trade my medicine. I will not take anyone else’s medicine.

I will not increase my medicine until I speak with my doctor or nurse.

My medicine may not be replaced if it is lost, stolen, or used up sooner than prescribed.

I will keep all appointments set up by my doctor (e.g., primary care, physical therapy, mental health, substance abuse treatment, pain management).

I agree to give a blood or urine sample, if asked, to test for drug use.

REFILLS

Refills will be made only during regular office hours—Monday through Friday, 8:00AM-4:30 PM. No refills on nights, holidays, or weekends. I must call at least three (3) working days ahead (M-F) to ask for a refill of my medicine. No exceptions will be made.

I must keep track of my medications. No early or emergency refills may be made.

PHARMACY

I will only use one pharmacy to get my medicine. My provider may talk with the pharmacist about my medicines.

PRESCRIPTIONS FROM OTHER DOCTORS

If I see another doctor who gives me a controlled substance medicine (for example, a dentist, a doctor from the Emergency Room or another hospital, etc.) I must bring this medicine to Primary Care in the original bottle or clearly document the prescription on the bottle (via photograph), even if there are no pills left.

TERMINATION OF AGREEMENT

If I break any of the rules, or if my provider decides that this medicine is hurting me more than helping me, this medicine may be stopped by my provider in a safe way.
(To sign, please use your mouse, trackpad, or finger to provide your signature. You cannot continue with the form until your signature for this part of the agreement is received.)
Signature*

Please sign agreeing to the terms and conditions of the controlled substances and prescriptions section. Clear

Informed Consent / Treatment Agreement
I agree to make a commitment to the treatment process. I understand this means I agree to active involvement in all aspects of treatment, including:
- Attending sessions (or letting my provider know when I cannot make it)
- Voicing my opinions, thoughts, and feelings honestly and openly, whether negative or positive
- Being actively involved during sessions
- Completing homework assignments
- Experimenting with new behaviors and new ways of doing things
- Taking medication as prescribed
- Implementing my crisis response plan
I also understand that, to a large degree, my progress depends on the amount of energy and effort I make. If it is not working, I will discuss it with my provider.
(To sign, please use your mouse, trackpad, or finger to provide your signature. You cannot continue with the form until your signature for this part of the agreement is received.)
Client's or Guardian's Signature*

By signing, you agree to the informed consent and treatment agreement Clear

Informed Consent for Telehealth Services
This Consent form does not replace PPCC’s primary Informed Consent Form for “In Office” mental health services; it is in addition to.

The definition of Telehealth involves the use of electronic communications to enable PPCC, INC mental health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, treatment, referral to resources, education, and the transfer of medical and clinical data. I understand:
1. The Florida laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is confidential. I understand during my telehealth sessions my provider will ensure a private and confidential environment and I agree to do the same at my location.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that there are risks and consequences from telehealth, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons.
4. I understand that if my counselor believes I would be better served by another form of intervention than telehealth, I will be referred to a mental health professional that can provide “in-person” services.
5. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.
6. I understand telehealth sessions shall not be recorded in any way by either the practitioner or client.
By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

I have read this document and understand the risks and benefits related to the use of telehealth services. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.

I hereby attest by signature that I have read, understood, and agree to the terms of this document.
Print Your Full Name*

First NameMiddle NameLast NameSuffix
(To sign, please use your mouse, trackpad, or finger to provide your signature. You cannot continue with the form until your signature for this part of the agreement is received.)
Signature of Client/Guardian*

By signing, you agree to the informed consent for telehealth services Clear
In case of an emergency, please list the emergency contact person we should call:
Emergency Contact Person*

First NameLast Name
Emergency Contact Person's Phone Number*

Notice of Protected Health Information and Communications
Pattison Professional Counseling and Mediation Center (PPCC Inc.) is dedicated in protecting your protected health information (PHI). You agree to the following services to release specified information while being treated at PPCC Inc.

PPCC Inc. places reminder calls one business day prior to your appointment. Your first name, the appointment time at our facility, and the clinician that you will be seeing will be released via a phone message, text, email, or appointment verification for smartphones.
Enter the phone number for text/phone message to be left*
PPCC Inc. secures your medical records electronically utilizing a HIPAA HYTECH compliant service.

If you and your therapist and/or our support staff communicate via email or texting through a cell phone, you agree to and understand that your PHI may be released via your correspondence and communications. PPCC Inc. secures your PHI however, once communication is released via the internet or phone devices your information is no longer secure.
Print Your Full Name*

First NameMiddle NameLast NameSuffix
(To sign, please use your mouse, trackpad, or finger to provide your signature. You cannot continue with the form until your signature for this part of the agreement is received.)
Signature of Client/Guardian*

Client/Guardian, by signing, you accept the communications policy above Clear

Financial Policy
Thank you for choosing Pattison Professional Counseling Center. We are committed to your successful treatment. The following is our financial policy, which we request you read, understand, and sign prior to treatment.

Insurance: Your insurance policy is between you and your insurance company. We are not a party to that contract. If services are not covered by your insurance policy, you are responsible for all session fees. We do accept the assignment of benefits from insurance companies with which we are participating providers. All Tricare/Champus clients must obtain a doctor’s referral in order to file the insurance claims. If the client does not obtain a referral and insurance cannot be filed, the client is responsible for the entire session charge. We will file your insurance claims for you, either by paper claim or electronically, unless otherwise specified by you.

Assignment of Benefits: I assign my insurance benefits to Pattison Professional Counseling Center for the duration of my treatment.

Payments: Self-pay patients (those paying the total amount) need to pay over the phone, or when making the appointment (as opposed to on the actual day of the appointment), to hold their spot. This is a non-refundable payment for the time slot (New patient: $250; Follow-Up [30-minute session] $175).

Clients using insurance will be expected to pay their co-pay on the day of service. If your co-payment is not known on the first date of service, a co-payment of $20.00 will be collected at the time of each session until your correct co-payment can be determined. We accept cash, checks, money orders, Visa, MasterCard, and American Express for payments. We can also keep your credit card number on file and charge your card with your cost share after each visit.

Missed or Cancelled Appointments: More than 48 hours of notification is required if you need to cancel or reschedule your appointment. The entire fee will be charged to your account if you do not show up for your scheduled appointment or do not give us more than 48-hour notification. Self-pay patients will have to pay the full fee again if giving less than 48-hours notice or missing the appointment. Insurance patients will be charged the full rate as a no-show fee prior to rescheduling if giving less than 48-hours notice or failing to show. If calling to cancel or reschedule your appointment after business hours, please leave your name, appointment date and time, and a brief message on our voice mail. We appreciate your assistance in helping us serve you better by keeping scheduled appointments.

Billing: Payment for all client statements is due in full upon receipt. A divorce decree cannot assign responsibility for an adult or child’s account. Failure to pay your bill could result in your account being turned over to a collection agency. Only your name and account status will be discussed with the collection agency.

Returned Checks: A $30.00 service fee will be added to your account for each returned check from your bank. Only cash payments will be accepted if two NSF checks are received.

My signature acknowledges that I have read, understand, and agree to all parts of the financial policy of Pattison Professional Counseling and Mediation Center (PPCC Inc). I also understand that my account will be turned over to a collection agency if it becomes delinquent.
(To sign, please use your mouse, trackpad, or finger to provide your signature. You cannot continue with the form until your signature for this part of the agreement is received.)
Signature of Client/Guardian *

Client, by signing, you understand and accept the financial policy for PPCC Inc Clear

Client Rights
I have the right to efficient and effective care individualized to my needs. My treatment provider will work with me to develop a treatment plan best suited to me. We will use this plan to help us deal with my problems as quickly and effectively as possible.

I have the right to be treated with dignity and respect. I will be treated with respect at all times. I will report any misconduct by my treatment provider, including social invitations, suggestive remarks, or unwanted touching, to PPCC management. I may call PPCC any time with questions, comments, or complaints.

My treatment provider will make every effort to meet me at our scheduled appointment time. If my treatment provider is late, he or she will extend our session, if I am willing, or we will make other arrangements by mutual agreement.

I have a right to privacy and confidentiality. All records and communications will be treated with confidentiality in compliance with applicable state and federal laws. These laws may obligate PPCC to report suspected abuse or neglect, domestic violence, and those who pose a danger to themselves or others, or when ordered to by a court of law.
Client Responsibilities
Scheduled appointments are commitments. I will make every effort to be on time for my appointment(s). I understand that time will be lost from my session if I am late for my appointment.

I am responsible to pay for services received. I am aware my insurance plan typically requires me to pay a co-payment (a dollar amount) or co-insurance (a percentage of my treatment provider's fee) at the time services are provided. My insurance plan may also have a deductible (an initial dollar amount) that is my responsibility. Additionally, certain services may be limited and/or not covered at all by my insurance plan. I understand I am financially responsible for co-payments, co-insurance, deductibles, and all services not covered by my insurance plan. My treatment provider and my insurance plan's representative will help me determine what services my insurance plan covers.

I have read this list of rights and responsibilities or had them read to me. I understand and agree to them.
Print Your Full Name*

First NameMiddle NameLast NameSuffix
Date*

MonthDayYear
Client, please enter the date of your acceptance of your rights and responsibilities as stated above
(To sign, please use your mouse, trackpad, or finger to provide your signature. You cannot continue with the form until your signature for this part of the agreement is received.)
Signature of Client/Guardian*

By signing, you are accepting the rights and responsibilities as stated above Clear
Should be Empty:

Psychiatric - Medication Management New Client Intake Form

Primary Insurance Information

Secondary or Supplemental Insurance Information

No Insurance

Medical History

Chief Concern

Psychological Symptoms

Mental Health History

Medical Condition History

Family History

Educational History

Goals for Treatment

Agreement for Controlled Substances and Prescriptions

Informed Consent / Treatment Agreement

Informed Consent for Telehealth Services

Notice of Protected Health Information and Communications

Financial Policy

Client Rights

Client Responsibilities