VIRTUAL VISIT Check In Form Morrison Clinic

  • This lobby check in form is for both psychiatric evaluations and established patient follow up visits and needs to be filled out prior to EVERY appointment.

  • Vital Signs

  • Heart Rate

  • Tele-Psychiatry Additional Information

  • Consent for the use of AI-Assisted Documentation

    Under Texas law, informed consent requires disclosure of the nature and purpose of a proposed intervention, along with its risks, benefits, and alternatives. This consent addresses the use of AI technology in documentation only. Your provider remains solely responsible for your medical care and decision-making.


    What This Technology Does

    • The AI tool listens to the conversation during your appointment.
    • It generates a draft clinical note summarizing the visit.
    • Your provider reviews, edits, and approves the final note before it becomes part of your official medical record.
    • The AI tool does not diagnose, recommend treatment, or make medical decisions.

    Potential Benefits

    • Allows your provider to focus more fully on you during the visit.
    • May improve efficiency and documentation completeness.
    • May reduce time spent typing during the session.


    Potential Risks

    • Technology-related errors or omissions in draft documentation.
    • Risk of unauthorized access despite security safeguards. 
    • Possible discomfort with audio-based documentation during sensitive discussions. 
    • Your provider reviews all AI-generated content for accuracy before finalizing your record.


    Privacy and Data Security

    • The AI tool is HIPAA-compliant.
    • Audio is used solely for documentation purposes.
    • Data is encrypted and handled according to federal and Texas privacy standards.
    • Information is not sold.
    • Recordings are not used for marketing purposes.


    Alternatives

    • You may decline the use of AI-assisted documentation.
    • If you decline, your provider will document the visit without AI scribe assistance.
    • Your care will not be affected by your decision.


    Voluntary Authorization
    Your authorization to use AI-assisted documentation is voluntary.

    You may:

    Decline before the visit begins.
    Withdraw consent at any time.
    Ask questions about how the technology works.
    Refusal or withdrawal of consent will not affect your access to treatment.

  • Patient Authorization


    By selecting “I Agree,” you acknowledge that:

    You have read and understand this disclosure.
    You have had the opportunity to ask questions.
    You voluntarily authorize the use of AI-assisted documentation during your visits.

  • Clear

  • MEDICATION COST AND COVERAGE: Your clinician is aware that out of pocket cost for medications factors into your ability to start and maintain treatment. Since medication changes only occur during medical appointments, it is important that you determine if you can afford prescribed medication during your medical appointment today. If your insurance denies coverage of a medication prescribed you will have to schedule another appointment in order to start a different medication or will have to pay for the medication out of pocket without your insurance. Goodrx.com offers coupons and discounts that often times make medications affordable without insurance so that you can avoid the cost of another medical appointment and can avoid a delay in getting your medication started.

  • Using your insurance medication cost estimator during your appointment is not a guarantee that your insurance will cover prescribed medication, but it does decrease the possibility that prescribed medication will be denied. As your clinician is discussing medication it is expected that you will be estimating and approving the out of pocket cost using Goodrx or your insurance medication cost estimator.

  • Insurance information for prior authorization processing during appointment.

    Using your insurance card, provide the following information. If you will not be using insurance to pay for your medication type in n/a.

  • Triage form

  • ---- SLEEP DISORDER RESPONSE TO CURRENT TREATMENT---

  • CURRENT MEDICAL ILLNESSES:

  • PSYCHOTHERAPY TREATMENT PLAN

  • Psychotherapy compliance

  • Psychotherapy Non Compliance

  • PSYCHOTHERAPY

  • ADHD TREATMENT

  • ----ADHD----

    Improvements should be based on what you think your symptoms would be in your current circumstances if you were not medicated for ADHD.

  • ---- ADHD INATTENTIVE AND HYPERACTIVE SYMPTOM RESPONSE TO CURRENT TREATMENT----

  • ----ADHD ANXIETY SYMPTOM RESPONSE TO CURRENT TREATMENT----

  • ----ADHD MOOD SYMPTOM RESPONSE TO CURRENT TREATMENT----

  • Untreated ADHD

  • MAJOR DEPRESSIVE DISORDER SYMPTOM RESPONSE TO CURRENT TREATMENT

    SYMPTOMS OF DEPRESSION AND MOOD DISORDERS INCLUDE: frequent feelings of depression or sadness, cognitive fatigue and slowing, low motivation for activities that normally lead to enjoyment, decreased activity level due to feeling sad or emotionally depleted, lack of interest in activities and people that normally lead to feelings of enjoyment, being bothered by thoughts that you would be better off dead or of hurting yourself in some way seeing or hearing things other people don't see or hear, delusional beliefs or paranoia that other people don’t believe

  • GENERALIZED ANXIETY DISORDER SYMPTOM RESPONSE TO CURRENT TREATMENT

    SYMPTOMS OF Generalized anxiety include: anxiety that leads to becoming easily annoyed or irritable , not being able to stop or control worry, feeling anxious, nervous, or on edge, anxiety that makes it hard to concentrate and is distracting, headaches from tension in neck and shoulders, anxiety that is draining and leads to fatigue

  • ----Panic Disorder Symptom Response to Current Treatment----

    Symptoms of panic disorder include severe and recurrent panic attacks that interfere with daily function. The panic attack is brief and discrete period of intense fear, anxiety, or discomfort with distressing physical symptoms of anxiety that occur out of the blue and are NOT due to being upset, stressed out, or worried. Within 10 minutes the anxiety has peaked and the feelings of panic do not last an extended period of time but are so intense that you avoid situations known to trigger the attacks. Panics can be triggered by situations in which escape might be difficult, not readily available, or would be embarassing.

  • ---- Social Anxiety Disorder: SMSAD----

    Instructions: The following questions ask about thoughts, feelings, and behaviors that you may have had about social situations. Usual social situations include: public speaking, speaking in meetings, attending social events or parties, introducing yourself to others, having conversations, giving and receiving compliments, making requests of others, and eating and writing in public.

  • ---- SOCIAL PHOBIA SYMPTOM RESPONSE TO CURRENT TREATMENT----

  • OCD: BOCS

    Please respond according to the situation during the last seven days (including today).

  • ---- OCD SYMPTOM RESPONSE TO CURRENT TREATMENT----

  • PTSD:PCL-C

    The next questions are about problems and complaints that people sometimes have in response to stressful life experiences. Please indicate how much you have been bothered by each problem in the past month. For these questions, the response options are: “not at all”, “a little bit”, “moderately”, “quite a bit”, or “extremely”.

  • PMDD SYMPTOM RESPONSE TO CURRENT TREATMENT----

    SYMPTOMS OF PMDD INCLUDE: fatigue, lack of interest, and decreased motivation the week prior to menstrual cycle, emotional sensitivity or sadness the week prior to menstrual cycle, worsening in concentration the week prior to menstrual cycle

  • Binge Eating Disorder SYMPTOM RESPONSE TO CURRENT TREATMENT----

    SYMPTOMS OF BINGE EATING INCLUDE:binging, inability to stop or control binge and during binge eats even when not hungry,  feeling embarrassed by binges, feeling guilty or disgusted with self after binge, or  binges occurring when unable to sit thru a negative emotion.  

  • Young Mania Rating Scale

    The YMRS is typically administered by a third-party clinician, but it is provided here, in a slightly reworded form, as a self-assessment. This may not be as accurate when self-administered, as people suffering from mania are often unable to properly assess relevant outward symptoms.There are 11 groups of statements in this questionnaire, read each group of statements carefully. Specify one of the choices that best describes the way you have been feeling for the past week by clicking the dot next to the appropriate statement.

  • Suicidal Ideation and Plan Assessment

  • WAIT TIME: While we do our very best to start your session at the assigned start time, please keep in mind that the average wait time to see a medical provider is 18 minutes. This typically occurs in instances where the clinician is running behind due to unforseen medical needs of patients scheduled before your time slot.

     

     Your time is valuable and we thank you in advance for your patience if the clinician is running behind. 

  • FORM SUBMISSION: AFTER YOU click submit you will be automatically directed to our virtual lobby check in.

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