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Psych Clearance New Patient Paperwork 
Psych Clearance New Patient Paperwork 
Psych Clearance New Patient Paperwork 
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    Please provide the Physician's name and fax number, so we are able to send the clearance letter:
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  • 5
    Please Select
    • Please Select
    • Alabama
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    • China
    • Christmas Island
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    • Comoros
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    • Lebanon
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    • Maldives
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    • Nigeria
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    • Philippines
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    • Rwanda
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    • Saint Helena
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    • Saint Lucia
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    • Sri Lanka
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    • eSwatini
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    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
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    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 6
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  • 8
    Please list below other individuals (family, spouse, parents) with whom your provider can discuss your care or release your psychiatric medical records.
    • Parent
    • Sibling
    • Spouse
    • Child
    • Friend
    • Do Not release Medical Information
    • Other
    • Parent
    • Sibling
    • Spouse
    • Child
    • Friend
    • Other
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  • 9
    All medications with the exception of controlled substances will be e-scribed to your pharmacy. Please provide your pharmacy information below
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  • 10

    Financial Policies and Benefit Assignment- Read and Sign

    I authorize Georgia Psychiatry & Sleep to furnish information as necessary to my insurance carrier regarding my illness and treatment, and I assign to Georgia Psychiatry & Sleep all insurance payments for medical services rendered. I understand that I am responsible for providing all necessary information to the office for submitting charges to the insurance company for payment. If I fail to provide this information, I accept the financial responsibility of payment for services rendered. This office has a cancellation policy that requires 24-hour advance notification. I understand that if I cancel with less than 24 hour notice, a charge will be made for the time reserved. This change is not covered by insurance and is not payable from any insurance company.

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  • 11

    Consent to treatment with psychotropic medications

    The indications for the medication(s) that are a part of my treatment plan have been discussed with me. I understand that, on occassion, some psychotropic medications may be used for psychiatric conditions or symptoms, despite a lack of FDA approval for these uses. I accept this, and accept the advantages and disadvantages of this treatment. After discussion with my provider and based on the information provided, I agree to comply with the instructions provided by my physician.

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  • 12

    Consent to treatment with TeleMedicine

    By signing this form, you agree that you have read, understand and agree with these terms if scheduled for a TelePsych appointment

    I confirm by my signature below that:

    I am aware of the provider that I am scheduled to have my telemedicine appointment with.

    I have been able to ask questions about telemedicine sessions with GPS staff.

    I am aware that I can reach out to the office if I have any other questions.

    I understand no guarantees have been made about success or outcome, and I agree to take part in a telemedicine appointment.

    I understand that the telemedicine consultation will be similar to a routine medical office visit.

    I understand that this is an option on a temporary basis due to the COVID-19 Pandemic.

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  • 13
    Listed below are all policies. All policies must be acknowledged and agreed to prior to the initial evaluation. Compliance with office policies are required. Please click each box after reading for acknowledgement. 
    1 of 9
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  • 14
    I have received and read the office policies, financial policy and patients' rights and responsibilities. 
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  • 15
    Answer required for each row
    1 of 9
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  • 16
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  • 17
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  • 18
    GAD-7 - Answer required for each row
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  • 19
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  • 20
    Answer required for each row
    1 of 14
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  • 21
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  • 22
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  • 23
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  • 24
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  • 25
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  • 26

    Are you living with Adult ADHD?

    Many adults have been living with Adult Attention Deficit/Hyperactive Disorder (Adult ADHD) and don't recognize it. These symptoms are often mistaken for a stressful life. If you've felt this type of frustration most of your life, you may have Adult ADHD - a condition your doctor can help diagnose and treat.

    The following questionnarie can be used as a starting point to help you recognize the signs/symptoms of Adult ADHD but is not meant to replace consultation with a trained healthcare professional. An accurate disagnosis can only be made through a clinical evaluation. Regardless of the questionnaire results, if you have concerns about diagnosis and treatment of Adult ADHD, please discuss your concerns with your physician.

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  • 27
    Check the box that best describes how you have felt and conducted yourself over the past 6 months. 
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  • 28
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  • 29
    • Never
    • Monthly or Less
    • 2-4 times a month
    • 2-3 times a week
    • 4 or more times a week
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  • 30
    • 0
    • 1-2
    • 3-4
    • 5-6
    • 7-9
    • 10 or more
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  • 31
    • Never
    • Less than monthly
    • Monthly
    • Weekly
    • Daily or almost daily
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  • 32
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  • 33
    Name of Hospital, City/state, Dates of treatment, Partial Hospital/intensive outpatient or inpatient, Reason
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  • 34
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    Name of Counselor/Psychiatrist, City/State, Dates Seen, Treatment Reason
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    Hospital Name, City/State, Dates, Reason
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  • 40
    Please select all that apply
    1 of 4
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  • 46
    • Married
    • Divorced
    • Single (Never Married)
    • Separated
    • Widowed
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  • 47
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  • 48
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  • 49
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  • 50
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  • 51
    • Employed
    • Unemployed
    • Disabled
    • Currently a student
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  • 52
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  • 54
    1 of 4
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  • 55
    If time was spent in jail/prison:
    1 of 2
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  • 56
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  • 57
    Honorable discharge / Other discharge, please explain. 
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  • 58
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  • 59
    • High School/GED
    • Some College
    • College Degree
    • Graduate Degree
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  • 60
    1 of 13
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  • 61
    Please check the following medical history conditions for yourself or close family members indicated.
    1 of 24
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  • 62
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  • 63
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  • 64
    Please describe
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  • 65
    • Yes
    • No
    • Former Smoker
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  • 66
    • Light smoker (1-9 cigs/day)
    • Moderate smoker (10-19 cigs/day)
    • Heavy smoker (20-39 cigs/day)
    • Very heavy smoker (40+ cigs/day)
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  • 67
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  • 68
    Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
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  • 69
    Medication / Strength / Prescriber / Dates used / Why did you stop?
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  • 70
    Type N/A if not applicable
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  • 72
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  • 73
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  • 74
    Clear
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  • 75
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    Pick a Date
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  • 76

    Please ensure to click SUBMIT following this screen.

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