Dr. Schroder - Preliminary Intake

Dr. Vincent Schroder - Preliminary Intake Form

Licensed Psychologist PY6063. 2630 NW 41 Street D-3, Gainesville, FL 32606
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Dr. Schroder is not accepting patients coping with addiction, who have ongoing legal issues, who are primarily seeking an evaluation, or any form of documentation, who have been diagnosed or told they have a personality disorder, bipolar disorder, brain injury, or who have suicidal ideation, a serious eating disorder or a recent history of self-harm. Please also note, Dr. Schroder is not a good fit for someone primarily seeking CBT or medications.*

NONE APPLY - Check box if none of these apply to you.ONE OR MORE APPLY - Check box if one or more of these apply to you.
Please stop here if you checked 'one or more', and see website information on potential referrals to find a better fitting provider.

https://www.vincentschroder.com/referral
Dr. Schroder is accepting new patients who have anxiety, stress, panic, mild depression, and/or relationship problems. Anyone with severe depression, trauma, stormy emotions is welcome. Similarly anyone with issues related to finding purpose, meaning, sorting out spirituality, sexual orientation and identity is most welcome. So too is anyone on the autistic spectrum, and anyone coping with attention deficit, cultural factors, or first-generation.*

ONE OR MORE APPLY - Check box if one or more of these apply to you.
If you agree that 'one or more apply', please continue.

Otherwise please see: https://www.vincentschroder.com/referral
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance - only Florida Blue, BlueCross, Medicare accepted.*
Insurance Member ID*
Upload FRONT/BACK image of your insurance card.

Browse Files
(Front image of insurance card) Cancelof
Browse Files
(Back image of insurance card) Cancelof
Less than 24 hour cancellation OR no-show fee = $30. Please keep in mind it's generally not possible for a therapist to fill a dedicated appointment time at the last minute. So this is just a way to partially compensate for this. We can discuss if needed.*

YesNo
I understand I am responsible for paying the full amount of services rendered not covered by my insurance. I further understand my share of the cost of services; for example, co-payments, coinsurances, and deductibles, will be collected utilizing my form of payment provided. You do not have to agree but please understand that Dr. Schroder is unable to provide services if you choose not to agree with this statement on patient's financial responsibility.*

Agree
Secondary / Additional Insurance
Secondary / Additional Insurance Member ID
Email*
example@example.com
Preferred Phone*

Area CodePhone Number
Preferred method of contact

EmailTextMobile Phone
What are your therapy-related goals? For example, identify a point in the future, perhaps a few months from now, describe how you any form of improvement or emotional healing you hope to achieve.
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Please describe, for example, all mental health professional(s) whom you've seen, what age at the time, the reason for treatment, how many sessions, and the outcome.
Marital Status
Employment
Primary Care Provider
Referral Name

First NameLast Name
Emergency Contact Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Medical History
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid Disease
Other Health History
Family history

AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal Disease
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Have you been convicted of drug related charges?

YesNo
Please describe any involvement with police or the legal system.
Are you currently taking prescription medication?

YesNo
Prescribing Doctor's Name

First NameLast Name
Prescribing Doctor's Phone

Area CodePhone Number
Have you had any surgeries in the past 5 years?

YesNo
Please describe/expand on any health concerns or history, especially any impacting your emotional functioning and psychological well-being.
Please list and briefly describe any other areas of concern - sleep, energy, food, finances, family, friends, health, etc.
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature*

Clear
One more thing! Please read the following.

Your signature indicates you agree and give consent as described.
CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS (TPO)

Federal regulations (HIPAA) allow me to use or disclose Protected Health Information (PHI) from your record in order to provide treatment to you, to obtain payment for the services we provide, and for other professional activities (known as “health care operations.”). Nevertheless, I ask your consent in order to make this permission explicit. The Notice of Privacy Practices describes these disclosures in more detail. You have the right to review the Notice of Privacy Practices before signing this consent. We reserve the right to revise our Notice of Privacy Practices at any time. If we do so, the revised Notice will be posted in the office. You may ask for a printed copy of our Notice at any time.You may ask us to restrict the use and disclosure of certain information in your record that otherwise would be disclosed for treatment, payment, or health care operations; however, we do not have to agree to these restrictions. If we do agree to a restriction, that agreement is binding.You may revoke this consent at any time by giving written notification. Such revocation will not affect any action taken in reliance on the consent prior to the revocation.This consent is voluntary; you may refuse to sign it. However, we are permitted to refuse to provide health care services if this consent is not granted, or if the consent is later revoked.I hereby consent to the use or disclosure of my Protected Health Information as specified above. I also attest to being provided a copy of Dr. Schroder’s Notice of Privacy Practices.
Signature*

Clear
T H A N K Y O U !

Please text me 352-372-9797 - tell me your name, and your available times on the hour M-Th 10am-5pm for the next couple of weeks.
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