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
Copyright © 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MDC is a trademark of Pfizer Inc.
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
and (list your previous provider or friend or family member that we can talk to about your care with):
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 $100 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.
To the extent possible, Michigan Psychiatric & Primary Care Clinic requests that you, as our patient will:
1. Provide accurate and complete information about your past illnesses, hospitalizations, medications, and other matter relating to your health, and answer any questions concerning these matters.
2. Participate in your health care planning by talking openly and honestly about your concerns with your provider and other health care professionals.
3. Understand your health problems, treatment course and care decisions to your own satisfaction and ask questions if you do not understand.
4. Cooperate with your provider and other health professionals in carrying out your health care plan as a patient (including communicating by returning emails and calls from the staff and providers).
5. Participate and cooperate with our health care professionals in creating a treatment plan that meets your psychiatric, medical, and social needs.
6. Inform the clinic or any of its professionals of the existence of any advanced directive (proxy, DNR, living will) you have created.
7. Take responsibility for the consequences and outcomes if you do not follow the care, service, or treatment plan.
8. Provide accurate information related to insurance or other sources of payment. You are responsible for ensuring payment of your bills and you may be responsible for charges not covered by your insurance. Requests or risk to commit insurance fraud will not be tolerated.
9. Treat other patients, visitors, and staff with respect and consideration. Support mutual consideration and respect by maintaining civil language and conduct in interactions with staff and providers. Abusive or threatening language or behavior directed at other patients, visitors or staff will not be tolerated.
10. Keep scheduled appointments and/or give appropriate notice of the need to cancel or reschedule your appointments.
11. Take medications as prescribed and follow dosage and transporting/care instructions.
12. It is not acceptable to try to alter or falsify official clinic documents, e.g. school notes, physical forms.
13. Follow instructions, policies, rules and regulations in place to support quality care for patients and a safe environment for all individuals at the clinic.
Michigan Psychiatric & Primary Care Clinic’s goal is to make the office a warm and welcoming place where patients receive holistic care. We put a lot of thought and care into establishing policies for patient and financial obligations. Failure to comply with one or more of the obligations listed on the Statement of Patient Responsibilities Policy and/or the Financial Agreement (signed during intake paperwork completion) are the primary reasons for patients being discharged from the clinic. It is important to read and understand these.
Patients who are discharged are determined with great consideration and the clinic does not make these decisions lightly. Our office will notify you via mail that you have been discharged by the clinic and will provide a 30-day window to find another provider (from the date of this letter). Acute care and support will be provided in that 30-day window following discharge, inclusive of medication if needed.
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.