Please complete all information on this form prior to your first visit. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you!
Emergency Contact Information
Please check all of the symptoms below that apply to you.
Suicide Risk Assessment
Past Psychiatric Medications
Please check all past medications.
Past Psychiatric Treatment
Medical Information and History
Family Medical History
Family Psychiatric History
Relationship History and Current Family
Family Background and Childhood History
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I authorize disclosure of records/information about me between:
Michigan Psychiatric & Primary Care Clinic, PC6110 Abbot RoadEast Lansing, MI 48823ph: 517.332.5342 | fax: 517.332.3325
Patient Restrictions on Methods for Disclosure
I have chosen to receive mental health services in the form of Psychiatric/Therapy sessions for myself from Michigan Psychiatric Primary Care Clinic. My decision is voluntary, and I understand that I may terminate these services at any time, unless my participation has been mandated by a court of law.
Nature of Mental Health Services
I understand that during my treatment I may need to discuss material of any upsetting or uncomfortable nature in order to resolve my problems. I also understand it cannot be guaranteed that I will feel better after completion of treatment.
Compliance with treatment plan
I agree to participate in the development of an individualized treatment plan. I understand that consistent attendance is essential to the success of my treatment. Frequent "no shows" and/or late cancellations (less than 24hr notice), which there is a $50 fee for every time, may be grounds for termination of services, as well as failure to follow my treatment plan in any form.
I understand I may reach Michigan Psychiatric and Primary Care Clinic at 517-332-5342. If not available, I can leave a message and my call will be returned as soon as possible. If I have a life-threatening emergency, I am to call 911 or go to my nearest Emergency Room.
BY SIGNING THIS, I AGREE I HAVE RECEIVED THIS PRACTICE'S NOTICE OF PRIVACY PRACTICES written in plain language. The Notice provides in detail the uses and disclosures of protected health information that may be made by this practice, individual rights and the practices' legal duties with respect to protect health information. The Notice includes:
This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice's current Notice of Privacy Practices on request.
BY SIGNING THIS POLICY YOU AGREE YOU UNDERSTAND AND AGREE TO BE BOUND BY THE FOLLOWING TERMS:
I have read and understand the practice's financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time without direct notice to me and agree to be bound by any amendments.