Internal Schedule Now / Patient Registration

Welcome to Mindful Care.

Click below to get started.
New Patient?*

YesNo
State Location*

New YorkNew JerseyIllinois
Returning Patients please call us at 516.505.7200 to schedule an appointment
Preferred Appointment Date:*

MonthDayYear
Date
Full name*

First NameLast Name
What is your preferred name? (How would you like to be addressed?)
Birth Date*
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Are you using Insurance for this visit?*

YesNo
Insurance Provider?*

1199 SEIUAetnaCignaEmpire Blue Cross Blue ShieldNYS The Empire PlanHealthFirstHumanaMedicareOptumOscarOxford Health PlanUnited Behavioral HealthUMRUnited HealthcareOther
Plan Name*
Plan Number
Group Number
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Upload a Picture of the front your insurance card*

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Upload a Picture of the back your insurance card*

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Address*

Street Address

Street Address Line 2

CityState

Zip Code
Do you have a different mailing address?*

YesNo
Mail Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact*

First NameLast Name
Emergency Contact Phone number*
Format: (000) 000-0000.
Gender*

MaleFemaleOtherNon-binaryTransgender M2FTransgender F2MPrefer not to say
What are your preferred pronouns?*

He/HimShe/HerThey/Them
How did you hear about us?*
Were you referred to Mindful Urgent Care?*

YesNo
Referred By*
Referral Source
Primary Care Physician
Primary Care Physician Phone
Format: (000) 000-0000.
Pharmacy Name / Pharmacy Address
Pharmacy Zip Code
Pharmacy Phone
Format: (000) 000-0000.
Pharmacy Address (in the event that we need to send medication prescriptions, now or in the future, please list your preferred pharmacy):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office location closest to you:*
Patient Health Information
What is the reason for your visit? *
Are you seeking help with us to avoid an ER visit for your mental health needs?*

YesNo
How long have you been experiencing these symptoms?

1 week1 month3 months6 months> 6 months
Are your symptoms directly related to the COVID-19 pandemic?*

YesNo
Have You Missed Any Days From Work Or School?*

YesNo
Have you seen a Psychiatrist, Psychologist, or Therapist in the past?*

YesNo
If So When?

MonthDayYear
Date
Past Psychiatric History - Check All That Apply*

ADHDAnger/OutburstsAnxietyBipolar DisorderDepressionEating DisorderPhobia(s)Obsessive Compulsive Disorder (OCD)Pre-Menstrual Dysphoric Disorder (PMDD)Post Traumatic Stress Disorder (PTSD)SchizophreniaSchizoaffective DisorderSuicide Attempt(s)Panic DisorderAlcohol AbuseOpioid AbuseSelf-HarmVisit the Emergency Department for mental health concernAttended facility for substance use disorderHospitalized for mental health concernFamily History of mental illnessOther Substance Use
Please check all of the following that apply to your psychiatric history.*

Visited the Emergency Department for a mental health concern.Hospitalized for a mental health concern.Attended a residential facility for a mental health concern.Attended an outpatient facility for rehabilitation or detox.Attended a partial-hospitalization program (PHP)?None of the above apply to me.
Have you experienced any of the following? (Check all that apply).*

Sexual abuseVerbal abusePhysical abuse/violenceNone of the above
What is your employment status?*

Working full-timeWorking part-timeNot working (by choice)UnemployedFull-time studentPart-time studentLeave of Absence from Work or SchoolDisabledRetiredVolunteering
Where do you live?*

HomeHome with parentsSchool campusGovernment-assisted housingHomelessOther
Are you pregnant or think you may be pregnant?*

YesNoThis question does not apply to me
Are you planning to become pregnant in the near future?*

YesNoThis question does not apply to me
Do you have any drug/medication allergies?*

YesNo
Please list drug/medication allergies:
Are You Currently taking any of the following medications?*

SSRISNRITricyclics/TCAOther AntidepressantsMood StabilizersAntipsychotic mood stabilizersSleeping pillsAnti-anxiety medicinesADHD medicinesI am not taking any of the medications listed aboveOther
Are you currently taking any psychiatric medications?*

YesNo
Please list the medications you are taking and their doses, including vitamins and herbal supplements. If you are not taking any medications, please list "none."*
Are you currently using any of the following substances? (Check all that apply).*

NicotineCannabisOpiates/Opioids/HeroinCocaineAmphetaminesAlcoholNone of the above
Medical History - Check All That Apply*

AnemiaAsthmaCancerChronic FatigueDiabetesEndocrine disorders (i.e. thyroid, pancreas, PCOS etc)Epilepsy/SeizuresFibromyalgiaHeart DiseaseHigh Blood PressureHigh CholesterolHIVInflammatory Bowel Disease (IBD)Irritable Bowel Syndrome (IBS)Kidney DiseaseLiver DiseaseMigrainesMultiple SclerosisSkin condition (i.e. psoriasis, eczema)StrokeTraumatic Brain Injury (TBI)None of the above applyOther
Family History - Check All That Apply*

ADHDAlcohol AbuseAnemiaAnger/ OutburstsAnxietyBipolar DisorderChronic FatigueChronic PainDepressionDiabetesDrug AddictionEating DisorderEpilepsy/SeizuresFibromyalgiaHeart DiseaseHigh Blood PressureHigh CholesterolKidney DiseaseNo known Family History
Are you taking any other medications?*

YesNo
Please list the medications you are taking and their doses, including vitamins and herbal supplements. *
What services are you interested in exploring? Check all that apply.*

Psychiatric Services (Medication Management)MindFit Group Therapy

Legal*

Rows	Yes	No
Is this visit court ordered?
Do you have pending legal problems?
Are you currently on probation/parole?
Is this visit related to a child protective order?
Have you been arrested in the past 12 - 24 months?

Treatment Plan

Week 1: Initial Evaluation (First Appointment)

Week 2- 11: A series of follow-up appointments focused on symptom stabilization and crisis management

Week 12: Transition visit to discuss long-term treatment options including ongoing continued care, discharge to higher level of care, or discharge to an alternate provider.

As a patient of Mindful Urgent Care, it is important to understand the journey of services that you will be provided. Mental health treatment can be complex; we also consider everyone’s life circumstances and acknowledge that everyone responds to medication differently. Each patient can expect the following services:
Acknowledgment of Treatment Plan*

I Acknowledge
Payment for Services:

Payment for Services: MUC is “in-network” with most insurance companies. MUC will bill my insurance after my visits; I authorize MUC to release medical records requested by my insurance company. I understand that my provider is legally obligated to collect all copays, deductibles, and /or coinsurance deemed to be the patient/insured responsibility by the insurance company. My co-payment, deductibles, and balance will be collected upon check-in. Some insurance plans require a referral from a physician (typically HMO plans). If a referral is required, it is my responsibility to know this and obtain the referral prior to the office visit. Missed appointments or failure to cancel your appointment within 24 hours, will be billed at $75.00 each appointment.
Acknowledgment of Payment of Services Policy*

I Acknowledge
Patient Contact Policy

MUC may contact you via email or phone regarding appointments, to discuss treatment, and/or with clinical updates. Your information will never be shared with third parties. All calls received during business hours will be returned within 24 hours. If a concern arises after-hours, please leave us a message. If emergent, due to a safety concern, please call 911 or go to the nearest emergency room.
Acknowledgment of Patient Contact Policy*

I Acknowledge
Termination of Care

It is your right to terminate services with us at any time.

We reserve the right to terminate services due to the following:

1. Consistently missed appointments

2. Inappropriate behavior

3. Seeking narcotics

4. Abusing/selling/trading medications

5. Non-adherence to your therapeutic plan

We also reserve the right to terminate services if the complexity of your case is beyond the scope of our provider.
Acknowledgment of Termination of Care Policy*

I Acknowledge
Medication Refill Policy

Please notify the office one week prior to needing a prescription refill. No refills will be called in after-hours or on weekends. In the event I lose medication, or do not attend follow-up appointments, my prescription may not be refilled.
Acknowledgment of Medication Refill Policy*

I Acknowledge
Confidentiality

Your medical records may be accessible to other clinicians in the office. Your personal information will NOT be released outside of MUC without your signed consent or a subpoena. Exceptions include suicide or homicide issues or child/elder abuse or neglect. Children (under the age of 17) have the right to confidential exchanges with clinician’s unless there are issues that pose immediate danger.
Acknowledgment of Confidentiality Policy*

I Acknowledge
Pregnancy Policy

I agree to inform my providers if I am, maybe, or planning to become pregnant.
Acknowledgment of Pregnancy Policy*

I Acknowledge
Payment Consent:

I hereby authorize Mindful Urgent Care to securely store my credit card and/or other payment details and charge it when my copayment and/or deductible is due upon check-in or should I have an outstanding balance or any leftover balance from a processed claim in the future.

Please indicate your agreement to the terms of this policy by signing below:
Upload a picture of the back of the card you would like on file*

Cancelof
Upload a picture of the front of the card you would like on file*

Cancelof
Acknowledgement of Payment Policy*

I Acknowledge
Mindful Urgent Care has a commitment to prescribing medications safely. We do not prescribe any controlled substances, habit-forming medications, or long-acting injectables. We do offer safer alternatives that can be reviewed at your visit.*

I acknowledge
Mindful Urgent Care offers medication management and support groups. We do not provide individual psychotherapy sessions. We do offer group therapy services that may be discussed with your provider during your evaluation.*

I acknowledge
Mindful Urgent Care Policies:
https://www.mindfulurgentcare.com/policies-and-informed-consent/

I acknowledge that I have reviewed all of Mindful Urgent Care's treatment and billing policies linked to above and agree to be seen under those policies.
Acknowledgment of Policies*

I acknowledge
Are you 18 years of age or older?*

YesNo
Adult Patient Consent to Care (18 years of age or greater)

I hereby authorize Mindful Care by and through its licensed medical professionals to provide me with mental health care services that such professionals deem necessary for diagnosing and/or treating my mental health condition(s). I hereby understand and agree that my sessions with Mindful’s mental health professionals may involve in-depth questions of a sensitive and personal nature including but not limited to such topics as (my history of diagnosed and/or undiagnosed mental health disorders and that of my family members, eating disorders, sexual history and/or abuse, history of suicidal and other self-harm tendencies and events, legal history/ history of interactions with law enforcement authorities, and substance use). I acknowledge and agree that if I am uncomfortable with the treatment outlined or line of questioning engaged in during my Mindful care session that I shall immediately notify my Mindful provider of such, so an alternative treatment regime may be utilized for my benefit. I acknowledge and agree that no guarantees and/ or assurances of any kind have been given to me concerning the results of Mindful’s mental health services including but not limited to the prospective improvement and/or resolution of my present mental health condition. I acknowledge and agree that I have been given the opportunity to ask questions concerning my pursuit of care with Mindful, and that all my questions have been answered to my satisfaction and that I am electing to pursue care with Mindful entirely of my own volition. My signature below indicates that I have fully read and agree to the aforementioned terms.
Acknowledgment of Consent*

I Acknowledge
Patient Signature*
Today's Date*

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Date
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Returning Patients please call us at 516.505.7200 to schedule an appointment

Patient Health Information