Psych Clearance New Patient Paperwork

1
Name* This field is required.
First Name
Middle Name
Last Name
2
Date of Birth* This field is required.
Date of Birth
Month
Day
Year
3
Reason for visit:* This field is required.
4
Who referred you to us?Please provide the Physician's name and fax number, so we are able to send the clearance letter:
Physician/ Other Name
Physician Fax Number
Physician/ Other Name
Physician Fax Number
5
Patient Home Address* This field is required.
Street Address
Street Address 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.
Area Code
Phone Number
7
Email* This field is required.
example@example.com
8
Release of medical informationPlease list below other individuals (family, spouse, parents) with whom your provider can discuss your care or release your psychiatric medical records.
Name
Parent
Sibling
Spouse
Child
Friend
Do Not release Medical Information
Other
Relationship
Name
Parent
Sibling
Spouse
Child
Friend
Other
Relationship
9
Pharmacy* This field is required.All medications with the exception of controlled substances will be e-scribed to your pharmacy. Please provide your pharmacy information below
Pharmacy Name, Address including ZIP, phone number, fax number
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.
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.
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.
13
Office Policies* This field is required.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.
Acknowledged
New patient no-show or same day cancellation fee of $100 will be required before our staff is able to reschedule an initial evaluation.
Exisiting patient no-show fee of $50.
A urine drug screen is required for ALL new patients and can be requested at any time at a follow-up visit for medication management, at the discretion of your provider. The UDS cost is $15.
Patients with 3 or more missed/cancelled appointments may be considered for possible termination from our practice.
There is a $25 fee for same-day cancellations. All cancellations will be considered on a case-to-case basis.
Patient's payment responsibility is due at the time of service.
Any medication refill requests will be considered on a case-to-case basis, and if approved by the provider, will be a cost of $25 if refilled without an appointment.
Insurance, address, phone number and pharmacy changes need to be updated with our office.
Any disability cases must require hospital based programs and will be referred out. Disability paperwork will NOT be evaluated and completed by this practice.
New patient no-show or same day cancellation fee of $100 will be required before our staff is able to reschedule an initial evaluation.
Exisiting patient no-show fee of $50.
A urine drug screen is required for ALL new patients and can be requested at any time at a follow-up visit for medication management, at the discretion of your provider. The UDS cost is $15.
Patients with 3 or more missed/cancelled appointments may be considered for possible termination from our practice.
There is a $25 fee for same-day cancellations. All cancellations will be considered on a case-to-case basis.
Patient's payment responsibility is due at the time of service.
Any medication refill requests will be considered on a case-to-case basis, and if approved by the provider, will be a cost of $25 if refilled without an appointment.
Insurance, address, phone number and pharmacy changes need to be updated with our office.
Any disability cases must require hospital based programs and will be referred out. Disability paperwork will NOT be evaluated and completed by this practice.
Acknowledged
Acknowledged
Acknowledged
Acknowledged
Acknowledged
Acknowledged
Acknowledged
Acknowledged
Acknowledged
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14
Terms and Conditions* This field is required.I have received and read the office policies, financial policy and patients' rights and responsibilities.
15
Over the last 2 weeks, how often have you been bothered by any of the following problems? (PHQ 9)* This field is required.Answer required for each row
Not at all
Several days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you have been moving around alot more than usual.
9. Thoughts that you would be better off dead or hurting yourself in some way
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you have been moving around alot more than usual.
9. Thoughts that you would be better off dead or hurting yourself in some way
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
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16
Total Score from questionnaire:
17
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?* This field is required.
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
18
Over the last 2 weeks, how often have you been bothered by the following problems? (GAD-7)* This field is required.GAD-7 - Answer required for each row
Not at all
Several days
More than half the days
Nearly every day
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
Not at all
Several days
More than half the days
Nearly every day
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19
Total score
20
Mood Disorder Questionnaire* This field is required.Answer required for each row
Yes
No
Has there ever been a period of time when you were not your usual self?
You felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
You were so irritable that you shouted at people or started fights or arguments?
You felt much more self confident than usual?
You got much less sleep than usual and found you didn't really miss it?
You were much more talkative or spoke much faster than usual?
Thoughts raced through your head or you couldn't slow your mind down?
You were so easily distracted by things around you that you had trouble concentrating or staying on track?
You had much more energy than usual?
You were much more active or did many more things than usual?
You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
You were much more interested in sex than usual?
You did things that were unusual for you or that other people might have thought were excessive, foolish or risky?
Spending money got you or your family in trouble?
Has there ever been a period of time when you were not your usual self?
You felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
You were so irritable that you shouted at people or started fights or arguments?
You felt much more self confident than usual?
You got much less sleep than usual and found you didn't really miss it?
You were much more talkative or spoke much faster than usual?
Thoughts raced through your head or you couldn't slow your mind down?
You were so easily distracted by things around you that you had trouble concentrating or staying on track?
You had much more energy than usual?
You were much more active or did many more things than usual?
You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
You were much more interested in sex than usual?
You did things that were unusual for you or that other people might have thought were excessive, foolish or risky?
Spending money got you or your family in trouble?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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21
Total number of "YES" responses:
22
If you answered YES to more than one of the above, have several of these ever happened during the same period of time?
YESNO
23
How much of a problem did any of these cause you- like being unable to work; having family, money or legal troubles; getting into arguments or fights?* This field is required.
No problem
Minor problem
Moderate problem
Serious problem
24
Have any of your blood relatives (i.e children, siblings, parents, grandparents etc) had manic-depressive illness or bipolar disorder?* This field is required.
YESNO
25
Has a health care professional ever told you that you have manic-depressive illness or bipolar disorder?* This field is required.
YESNO
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.
27
Adult Self Report Scale* This field is required.Check the box that best describes how you have felt and conducted yourself over the past 6 months.
Never
Rarely
Sometimes
Often
Very Often
1. How often do you have trouble wrapping up the final detail of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things done in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
1. How often do you have trouble wrapping up the final detail of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things done in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
Never
Rarely
Sometimes
Often
Very Often
Never
Rarely
Sometimes
Often
Very Often
Never
Rarely
Sometimes
Often
Very Often
Never
Rarely
Sometimes
Often
Very Often
Never
Rarely
Sometimes
Often
Very Often
Never
Rarely
Sometimes
Often
Very Often
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28
Total Score:
29
How often do you have drinks containing alcohol?* This field is required.
Never
Monthly or Less
2-4 times a month
2-3 times a week
4 or more times a week
30
How many standard drinks containing alcohol do you have on a typical day?* This field is required.
0
1-2
3-4
5-6
7-9
10 or more
31
How often do you have six or more drinks on one occasion?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
32
Have you been a patient in a psychiatric hospital or in a rehab program for a drug/alcohol problem?* This field is required.
YESNO
33
If you answered YES to the last question, please provide:Name of Hospital, City/state, Dates of treatment, Partial Hospital/intensive outpatient or inpatient, Reason
Huge
Large
Normal
Small
Ok
Ok
34
Have you ever seen a psychiatrist or counselor in the past?* This field is required.
YESNO
35
If you answered YES to the last question, please provide: Name of Counselor/Psychiatrist, City/State, Dates Seen, Treatment Reason
Huge
Large
Normal
Small
Ok
Ok
36
Any prior major medical (non-psychiatric) hospital admissions?* This field is required.
YESNO
37
If YES, please provide:Hospital Name, City/State, Dates, Reason
Huge
Large
Normal
Small
Ok
Ok
38
Major surgeries:
39
Do you have a history of addiction?* This field is required.
Yes
No
Ongoing
Past
40
Drug of choice:Please select all that apply
Yes
No
Alcohol
Marijuana
Opiates
Other substances
Alcohol
Marijuana
Opiates
Other substances
Yes
No
Yes
No
Yes
No
Yes
No
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41
If other substance abused, please explain:
42
Last use:
43
If you have an active addiction, what is your longest period of sobriety?
44
Have you experienced drug withdrawals?* This field is required.
YESNO
45
Do you attend AA/NA/12- Step Meetings?* This field is required.
YESNO
46
Marital Status:* This field is required.
Married
Divorced
Single (Never Married)
Separated
Widowed
47
If MARRIED, how many years?
48
If DIVORCED, how many years?
49
Number of prior marriages?
50
Number of children?
51
Employment Status* This field is required.
Employed
Unemployed
Disabled
Currently a student
52
If EMPLOYED, what is your position/employer?
53
If DISABLED, for medical or psychiatric condition? Explain.
54
Legal History* This field is required.
Select all that apply:
No legal problems
Spent time in jail
Now on probation
Court-ordered treatment
No legal problems
Spent time in jail
Now on probation
Court-ordered treatment
Select all that apply:
Select all that apply:
Select all that apply:
Select all that apply:
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55
Legal historyIf time was spent in jail/prison:
Please explain
Spent time in jail for(reason):
Total time in jail/prison:
Spent time in jail for(reason):
Total time in jail/prison:
Please explain
Please explain
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56
Have you served in the US military?* This field is required.
YESNO
57
If YES, number of years and reason for discharge? Honorable discharge / Other discharge, please explain.
58
Cultural Identity (Ethnicity/Religion)* This field is required.
59
What is your highest level of education?* This field is required.
High School/GED
Some College
College Degree
Graduate Degree
60
Review of Systems* This field is required.
YES
NO
Generally healthy
Changes in weight or changes in strength or exercise tolerance
Headaches, vertigo, injury
Changes in hearing, ringing in ears, bleeding, vertigo
Nose bleeds, colds, obstruction, discharge
Dental difficulties, gingival bleeding, use of dentures
Chest pains, palpitations, fainting, shortness of breath, irregular heartbeat
Change in appetite, abdominal pains, bowel habit changes
Urinary urgency, painful urination, change in nature of urine
Change in menses, cramping, pelvic pain
Pain in muscles or joints, limitation of range of motion, tingling or numbness
Weakness, tremor, seizures, changes in mental function, problems with muscle coordination
Changes in sleep habits, difficulty sleeping, insomnia
Generally healthy
Changes in weight or changes in strength or exercise tolerance
Headaches, vertigo, injury
Changes in hearing, ringing in ears, bleeding, vertigo
Nose bleeds, colds, obstruction, discharge
Dental difficulties, gingival bleeding, use of dentures
Chest pains, palpitations, fainting, shortness of breath, irregular heartbeat
Change in appetite, abdominal pains, bowel habit changes
Urinary urgency, painful urination, change in nature of urine
Change in menses, cramping, pelvic pain
Pain in muscles or joints, limitation of range of motion, tingling or numbness
Weakness, tremor, seizures, changes in mental function, problems with muscle coordination
Changes in sleep habits, difficulty sleeping, insomnia
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
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61
Medical History* This field is required.Please check the following medical history conditions for yourself or close family members indicated.
Myself
Mother
Father
Sibling
Bipolar disorder
Depression
Anxiety
Addiction
Attention Deficit Disorder
Other psychiatric illness
Family history of completed suicide
Heart disease/Structural cardiac heart defects
Sudden cardiac death (sudden heart attack n their 20's or 30's)
Heart arrhythmias
Seizure disorder
High Blood Pressure
Thyroid Disease
Kidney Disease
Liver Disease (Hepatitis/Cirrohsis)
Sleep Apnea
Narcolepsy
Autoimmune disease
Diabetes
Coronary Artery Disease
Stroke
Chronic Kidney Disease
Congestive Heart Failure
None of these apply
Bipolar disorder
Depression
Anxiety
Addiction
Attention Deficit Disorder
Other psychiatric illness
Family history of completed suicide
Heart disease/Structural cardiac heart defects
Sudden cardiac death (sudden heart attack n their 20's or 30's)
Heart arrhythmias
Seizure disorder
High Blood Pressure
Thyroid Disease
Kidney Disease
Liver Disease (Hepatitis/Cirrohsis)
Sleep Apnea
Narcolepsy
Autoimmune disease
Diabetes
Coronary Artery Disease
Stroke
Chronic Kidney Disease
Congestive Heart Failure
None of these apply
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
Myself
Mother
Father
Sibling
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62
If applicable, are you currently pregnant?* This field is required.
Yes
No
N/A
63
If applicable, are you currently breast-feeding or pumping breast milk for infant feedings?* This field is required.
Yes
No
N/A
64
Do you have any other chronic medical conditions?Please describe
65
Do you smoke cigarettes?* This field is required.
Yes
No
Former Smoker
66
If YES, how many per day?
Light smoker (1-9 cigs/day)
Moderate smoker (10-19 cigs/day)
Heavy smoker (20-39 cigs/day)
Very heavy smoker (40+ cigs/day)
67
Taking any medications, currently?* This field is required.
Yes
No
68
If yes, please list it herePlease list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
69
List any psychiatric medications you have tried in the past:* This field is required.Medication / Strength / Prescriber / Dates used / Why did you stop?
Huge
Large
Normal
Small
Ok
Ok
70
Are you allergic to any medications?* This field is required.Type N/A if not applicable
71
Current Height:* This field is required.
72
Current Weight:* This field is required.
73
I give consent to retrieve all medication records from pharmacy and/or prescribers?* This field is required.
YESNO
74
SIGNATURE* This field is required.
Clear
75
Today's Date:* This field is required.
Date
Month
Day
Year
76
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