Adult Psychiatric Intake Packet

Patient First Name:
Patient Last Name:
DOB:

MonthDayYear
Preferred Pharmacy (in the event that you are prescribed medications, they will be sent electronically to the pharmacy listed here):

Rows	Pharmacy	Address	Number

What are your treatment goals?

Rows
1.
2.
3.

What are the current problems for which you are seeking help?

Rows
1.
2.
3.

Current Medications (Please include all medications you take for any reason, even if you do not take them daily. Please include any prescription medications, as well as over-the-counter medications, vitamins and supplements.) Write N/A if none:

Rows	Name of Medication:	Dose:	How many times a day:	Reason for medication

Do you have any allergies (Medications, Foods, etc)?
Rows Name of allergen: Reaction:
Current approximate weight and height:
Weight (in lbs)
Height (in ft and inches)
Name of your current Primary Care Provider (enter N/A if not applicable).
Date of your last physical / lab work

Rows	Name of allergen:	Reaction:

Current/Past MEDICAL History:
Are you currently or have you ever been diagnosed with the following (place X in the appropriate boxes). Write N/A in the "other" box if none:

Rows	Current:	History of:
High Blood Pressure
High Cholesterol
Head Trauma
Seizure or Epilepsy
Obesity
Diabetes
Thyroid Disease/problems
Liver Disease/problems
Kidney Disease/problems
Heart Disease/problems
Asthma/respiratory problems
Other (Please List):.

Past MEDICAL hospitalizations or surgeries (write N/A if none):

Rows	Year:	Reason for hospitalization or surgery:
1
2
3

Past PSYCHIATRIC History
Are you currently or have you ever been diagnosed with or experienced the following: (place X in the appropriate boxes)

Rows	Current:	History of:
Depression
Anxiety (Including panic)
Mania (or Bipolar Disorder)
Hallucinations, delusions, or psychosis
Trauma or PTSD
Obsessions/compulsions (OCD)
ADHD
Disordered eating
Problems with substance use
Questions related to gender identity
Suicide or suicide attempts
Violence

Other- please list:
Family Psychiatric History

Has anyone in your family ever been diagnosed with or experienced the following:(place X in the appropriate boxes)

Rows	Current or History of:	Relation to you:
Depression
Anxiety (Including panic)
Mania (or Bipolar Disorder)
Hallucinations, delusions, or psychosis
Trauma or PTSD
Obsessions/compulsions (OCD)
ADHD
Disordered eating
Problems with substance use
Questions related to gender identity
Suicide or suicide attempts
Violence

Other- please list:

Past PSYCHIATRIC hospitalizations, rehabilitations, detoxes, and/or residential stays (Write N/A if none):

Rows	Year	Location (Institution name and/or city)	Reason for stay:
1.
2.
3.

Past PSYCHIATRIC medications:(please start with most recent medications). Write N/A if none.

Rows	Name of medication:	Highest dose:	Start/End Date (or approx length of therapy if unsure)	What did you like/not like?	Side effects?
1.
2.
3.
4.
5.
6.

Other treatments/medications previously used to treat symptoms if they do not fall under Psychiatric Medications (e.g. TMS, ECT, Psychedelics, Acupuncture, Supplements, Hypnosis). Write N/A if none.

Rows	Name of treatment/medication:	Highest dose:	Start/End Date (or approx length of therapy if unsure)	What did you like/not like?	Side effects?
1.
2.
3.

Current wellness/desire for change:

Rows	Please make a choice
I am satisfied with my current sleep routine.
I am satisfied with my current dietary habits.
I am satisfied with my current level of exercise/movement.
I am satisfied with my current relationship with screens/social media.
I am satisfied with my relationships/social connection.
I am motivated to make changes to my current sleep routine.
I am motivated to make changes to my current dietary habits.
I am motivated to make changes to my current level of exercise/movement.
I am motivated to make changes to my current relationship with screens/social media.

Any other areas of wellness you would like to address?
Signature
Date

MonthDayYear
Date

MySpectrum Counseling & Coaching
Psychiatric Services Informed Consent
I, *, (Patient/Legal Guardian) do voluntarily consent to psychiatric care and treatment through MySpectrum Counseling & Coaching.
General/Appointments and Fees:

I understand that our work will be kept confidential with the exception of disclosures required by law and when necessary in connection with my care. In particular, I am aware that, although my Psychiatric Nurse Practitioner (PMHNP) is a clinically independent practitioner, consultations with associates are at times clinically advisable and my signature below gives my PMHNP permission to do that. My PMHNP works collaboratively with my Therapist to ensure that everyone is working together to best support my needs.
- Professional Forms: completion of forms for employment, school, return-to-work, disability, retirement, legal action, etc. Forms can take up to 10 business days to complete from the time of the request and fees are pro-rated at the hourly rate of $200.
- Letters: incur a pro-rated hourly fee of $200, billable in 15 minute increments and payment is due prior to completion of the letter. This includes, but is not limited to, forms pertaining to insurance, employment, return-to-work status, school, disability, retirement, and legal action. Letters may take up to10 business days to complete from the time of the request.
- Subpoena for Witness: If my PMHNP is subpoenaed for court, the fee is $200 per hour, and if significant travel is warranted, the fee is a minimum of $1600 for the day.
- Refill Requests Between Appointments: A $55 fee will be incurred for refill requests that occur when an appointment has been missed or canceled by the patient.

I have the right to revoke this consent in writing and terminate services with my Psychiatric Nurse Practitioner at any time.
1. “I have read and understand the information on this sheet. My signature below indicates my informed consent with MySpectrum Counseling & Coaching.”
2. It is helpful that we make contact with your Primary Care Physician (PCP) and your Therapist or their providers (if applicable) to coordinate your care. If you object to this, please indicate below and this will be discussed in your first session.
Yes, I consent to sharing information with my other providers.
No, do not share information at this time

3. An E-mail and text reminder is automatically provided if you offer your E-mail address and phone number
Email@ *
Phone@  *
Signature of Person Agreeing to Treatment
Date

MonthDayYear
Date
Parent/Legalguardian signature (Put "N/A" here if not applicable)

Telebehavioral Health Safety Plan
Instructions: In order to receive telebehavioral health services at MySpectrum, all questions on this form must be answered. If you move, you are responsible for updating your address with our practice and filling out a new form. If you are in a different location from what is listed below, you are responsible for informing your provider at each session. For anyone to be present in your session, your provider must agree that it is clinically appropriate and there must be a signed release on file prior to the session (unless the other person is your Legal Guardian). It is strongly recommended that your children are not present for your session, unless it is planned that they be involved in the session. If at any time these policies or your conditions of informed consent are not followed, your session will be ended and you will be charged our private pay rate.

1. What address will you be located in during your telehealth session? Must be located in Virginia unless otherwise discussed with MySpectrum to ensure that your provider is licensed in the state where you will physically be located at the time of your session.
Street Address: Apt #
City: State: Zip Code:
If meeting in multiple locations list a second option:
Street Address: Apt #
City: State: Zip Code:
2. Do you have a reliable connection to wifi:
3. What is the best number to reach you if we lose our connection?
Please enter a valid phone number.Format: (000) 000-0000.
4. Do you have access to a private location to meet with your provider? Private is defined as the ability to meet via teleconference with video and audio without any other person including children in the room.
5. Please provide the local police department and their non emergency number below:
Police DepartmentFormat: (000) 000-0000.
If yes, please list:
6. We require an emergency contact to call if your provider can not get in touch with you to ensure your safety. Please list their contact information and complete and submit a release form:
Name
Relationship to you
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are they located in your home:
By signing this form, I agree to and I understand the following: I agree to allow MySpectrum to call the above emergency contact if my provider is not able to reach me. I agree to inform my provider at each session if I am located at a location that is not listed on this form. I understand that I must fill out all sections of this form or I can not engage in telebehavioral health at this practice.
Printed Name of Patient or Parent/Legal Guardian:
Signature of Patient or Parent/Legal Guardian
Date

MonthDayYear
Date

Past PSYCHIATRIC History

Telebehavioral Health Safety Plan

Release of Information