Pinnacle Behavioral Health IPA LLC

2023 Patient Information & Questionnaire

Pinnacle Behavioral Health IPA, LLC - 10 McKown Rd Albany, NY 12203
Name*

First NameLast Name
Preferred Name
Phone Type*
Choose Phone Type
Phone Number *

Area CodePhone Number
Phone Type
Additional Phone Number
Phone Number *

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*
DD/MM/YEAR
Gender

MaleFemale
Emergency Contact*

First NameLast Name
Emergency Contact Relation to Patient
Relation to Patient
Emergency Number*

Area CodePhone Number
Primary Care Physician
Primary Care Number

Area CodePhone Number
What service are you seeking?*

Medication ManagementIndividual TherapyGroup TherapyTMS
Insurance Information
Primary Insurance
ID #
Group #
Subscriber
Secondary (If applicable)
ID #
Group #
Subscriber
Questionnaire
Briefly, what would you like to discuss with your clinician? Who referred you, or what motivated you to seek assistance?*
What are your most distressing symptoms (Ex. anxiety, sleep problems, attention)?*
Have you experienced any frequent or intense interest or plan of seriously harming or killing yourself or someone else? Have you ever tried to do something like this in the past? If so, please indicate and discuss in detail with your clinician. *
Do you drink alcohol often or in large amounts, or use tobacco, marijuana or illegal drugs? *
Where and with whom do you presently live? Please list those who are closest to you, and any recent or impending changes in your living situation. *
Are you in school? If so, where? *
Are you working? If so, where and for how long? *
Are you a party to any ongoing legal matter (criminal, family court, divorce, lawsuit)?*
Are you requesting paperwork or notification for a third party (Ex. a court hearing, return to or leave from absence from work or school)?*
Please list any medical or other health problems that are currently being managed.*
Height *
Weight*
Please list the names and dosages of all prescription or over-the-counter medications you regularly take, along with any food or drug allergies.*
Patient Signature validating above answers are truthful and correct to the extent of your knowledge.*

Clear
I consent to the use or disclosure of my protected health information by Pinnacle Behavioral Health IPA, LLC for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct the healthcare operations of Pinnacle Behavioral Health IPA, LLC. I understand that my diagnosis by Pinnacle Behavioral Health IPA, LLC may be conditioned upon my consent as evidenced by my signature on this document. Signature:*

Clear
I understand that Pinnacle Behavioral Health IPA, LLC Notice of Privacy Practices describes the types of uses and disclosures of my protected mental health information that may occur in my treatment, payment of my bills or in the performance of the health care operations of Pinnacle Behavioral Health IPA, LLC. I acknowledge that a copy of Pinnacle Behavioral Health Privacy Practices has not been handed to me. Signature:*

Clear
If you are not able to make your appointment please notify our office at least 24 HOURS prior to the appointment. We reserve the right to charge a late fee for appointments cancelled within a 24 hour notice. Our fee is $60 for counseling and $100 for Medical. Signature:*

Clear
Date*

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

2023 Patient Information & Questionnaire

Insurance Information

Questionnaire