New Patient Questionnaire

New Patient Questionnaire

Thank you for taking the time time give us this important information.
Today's date*

MonthDayYear
Date
Patient’s Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Preferred Name
Preferred pronouns
Biologic sex*

MaleFemale
Patient's Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Person completing this form*
Relationship to patient*
Who referred you?
What is your preferred pharmacy?*
Please describe, in detail, the reasons for which you are seeking help at this time.*
Approximately when did the problem(s) begin?*
Any known stressors that may have caused or contributed to the problem(s)?*
History of threatened or attempted suicide? *
History of self harm?*
Ever received any mental health treatment or testing?*

YesNo
Is the patient currently taking any medications (including over the counter, vitamins, or supplements)?*

YesNo
Ever taken any medications to help with mental health symptoms including thinks like depression, anxiety, sleep, or ADHD?*

YesNo
Ever received mental health treatment in a hospital?*

YesNo
Is there any history of mental health conditions in biological family?*

YesNo
Family Mental Health History

Please note ADHD, learning disorders, depression, bipolar disorder, anxiety, obsessive-compulsive disorder, tic/Tourette’s, schizophrenia, drug or alcohol abuse, suicide attempts, or other mental health conditions in the patient's biological parents, grandparents, siblings, or first cousins. (If there is no family history of mental health conditions, type "none" in any box)*

	Family Member	Mental Health Condition	Type of Treatment (if any)

Outpatient Mental Health Treatment History

Please tell us about therapy, counseling, psychological testing, and any other help received. (If there is no history of previous mental health treatment, type "none" in any box)*

	Name of clinician	Dates of Treatment	Type of Treatment

Mental Health Medication History

Please list medications that have been taken for mental health symptoms. (If the patient has never been prescribed mental health medications, type "none" in any box)*

	Name of Medication	Dosage	Dates Taken	Helpful?	Side Effects?

Inpatient Mental Health Treatment History

Please list any hospitalization information. (If there is no history of mental health hospitalization, type "none" in any box)*

	Name of Hospital	Dates of hospitalization	Reason for admission

Developmental History
Please check any that apply to the mother’s pregnancy with this child.

Received prenatal careTook medicationsAlcohol useTobacco UseIllicit substance useSevere emotional distressOther
Mother's age at time of birth
Father's age at time of birth
Birth weight
Born premature?

YesNo
How many weeks?
Any complications with delivery?

Developmental Milestones (answer as best you can recall)

	Slow	Normal	Fast
Motor Development (crawling, walking, etc.)
Speech Development
Self help skills (toileting, hygiene, etc.)

Medical History
Current primary care provider*
Any known medication allergies?*

YesNo
Please list name(s) and type of allergic reaction(s)
Please list any medical problems
(Ex: asthma, diabetes, heart condition, seizures, hearing problems, vision problems, etc.)
Please list any surgeries that have been done

Please list all current medications including those that are over the counter, vitamins, and supplements. (If the patient does not take any medications or supplements, type "none" in any box)*

	Name of Medication	Dosage	Frequency	Prescriber

Rating Scales

** This section may include questions that must be answered by the patient directly **
Is the patient 18 years or older?*

YesNo
Do you have concerns or current diagnoses for any of the following:*

AnxietyDepression
Does your child have concerns or current diagnoses for any of the following:*

AnxietyDepressionADHD

Consent for Text and Email
I hereby consent and state my preference to have staff at Willow Youth Mental Health communicate with me by email or standard SMS messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing.

I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my medical care might be intercepted and read by a third party.
I prefer to receive SMS text messages and voice messages at the following number:*
Phone Number
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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CONSENT TO OBTAIN PRESCRIPTION HISTORY
Our medical practice has adopted an electronic medical record system in order to improve the quality
of our services. This system also allows us to collect and review your “medication history.” A
medication history is a list of prescription medicines that we or other doctors have recently prescribed
for you. This list is collected from a variety of sources, including your pharmacy and your health
insurer.

An accurate medication history is very important to helping us treat you properly and avoiding
potentially dangerous drug interactions.

By signing this consent form you give us permission to collect, and give your pharmacy and your health
plan permission to disclose information about your prescriptions that have been filled at any pharmacy
or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and
medicines used to treat mental health conditions, such as depression. This information will become
part of your medical record.

This medication history is a useful guide, but it may not be completely accurate. Some pharmacies do
not make drug history available to us, and the drug history from your health plan might not include
drugs that you purchased without using your health insurance. Your medication history might not
include over the counter medicines, supplements or herbal remedies. It is still very important for us to
take the time to discuss everything you are taking, and for you to point out to us any errors in your
medication history.
By signing below I give permission for Willow Youth Mental Health to obtain my medication history
from my pharmacy, my health plan/s and my other healthcare providers.
Signature of Patient/Legal Guardian if over 18 years old

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Today's Date

MonthDayYear
Date
Patient's Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date

CONSENT TO PARTICIPATE IN TELEHEALTH SERVICES

Laura Smith, MD	Nicole Barlow, LPC
Tara Herren APRN-CNP	Carolyn Chapman, LPC
Kenny Le, PA-C	Heather Baker, LCSW

Our practice implements telehealth virtual visits via interactive video conferencing for medical evaluation and management as well as psychotherapy. The necessary frequency and duration of these services will be determined by your provider. All services provided comply with all of the HIPAA Privacy and Security requirements.

1. Purpose. The purpose of this form is to obtain your consent to participate in
telehealth services provided.

2. Your Rights. You may withhold or withdraw your consent to the telehealth service at
any time before or during the visit without affecting the right to future care or
treatment.

3. Risks and Benefits. Please initial to indicate you have read each statement and
understand it.
I understand there may be limitations to image quality or other electronic problems that are beyond the control of the provider.*
Initials
I understand that delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.*
Initials
I understand that in some instances, security protocols could fail, causing a breach of privacy of personal medication information.*
Initials
I understand that in lieu of this telehealth encounter, I may seen healthcare elsewhere where I might have a face-to-face contact with the healthcare provider. *
Initials
I understand that there are no guarantees with telehealth services.*
Initials
Signature of Patient or Legal Guardian*

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By signing below, I agree that I have received an explanation of how the video and audio technology will be used to conduct the telehealth service, and I understand there are limitations to the technology and the process of telehealth, including the potential for incomplete exchange or loss of information. I understand the written information provided above, and I hereby voluntarily and freely agree and give my consent to take
part in the telehealth service and to any related evaluation, assessment and diagnosis as the consulting health care provider deems appropriate.
Printed Name*

First NameLast Name
Relationship to Patient (If applicable)
Date*

MonthDayYear
Date

OFFICE POLICIES

Effective 01/2023
Appointments
Patients will be seen by appointment only. Same day appointments may be made available in the event of an emergency. To schedule an appointment, call 405-400-1152.*
INITIALS
Our system will notify you (48 hours) ahead of your appointment and you are expected to notify us if you need to cancel. The no show/late cancellation (less than 24-hour notice) policy is strictly enforced. Two no-shows/late cancellations in a 6-month period will result in discharge from our clinic.*
INITIALS
If you do not attend the visit and fail to give advance notice, a fee of $65 will be incurred.*
INITIALS
If you are more than 15 minutes late for your appointment the appointment will need to be rescheduled and a late cancellation charge will be incurred.*
INITIALS
For in office visits, please arrive no later than 10 minutes prior to your appointment time in order to complete the required forms and get properly checked in.*
INITIALS
For virtual visits, please complete the appointment check-in form and any related questionnaires prior to your appointment time. Failure to check in by your appointment time may result in your appointment being canceled and considered a ‘No Show’.*
INITIALS
Unless specifically discussed with your provider ahead of the visit, a guardian that is familiar with the patient’s progress must be present for the duration of the appointment.*
INITIALS
Telemedicine visits should be conducted in a private place with adequate internet connection. Visits should not be conducted in moving vehicles or public places. If the doctor deems it necessary to cancel your appointment after it has started because either of these criteria are not met, a late cancellation charge may be applied.*
INITIALS
After-hours, Emergency and Holiday Coverage
Our regular office hours are Monday-Friday 8am-5pm. If you are calling after-hours about a matter that does not necessitate immediate attention please leave a voicemail and we will return your call as soon as possible. However, if you are suicidal, fear that you will do harm to yourself or others, suspect you are having a severe allergic reaction to a medication, or face a life-threatening emergency, please call "911" or go to the nearest emergency room. You should instruct the emergency room to notify your provider. For the sake of continuity of care, we ask that you bring any discharge instructions or medication adjustments to your next appointment.*
INITIALS
Refills and Prescriptions
I understand that any changes to medications must be made by a provider during an appointment, I will not make changes to my/my child's medications unless directed by the provider to do so.*
INITIALS
I understand that medications are prescribed to assist in reaching treatment goals and consistent adherence is crucial for effective treatment. *
INITIALS
Prescriptions will not be refilled after hours or on weekends, so please plan accordingly. Refills will be processed within 3 business days.*
INITIALS
We reserve the right to decline issuing prescription refills if medications have been lost or stolen, if you have missed an appointment.*
INITIALS
Refills will not be sent if you have not been seen within the last six months.*
INITIALS
A follow-up appointment must be scheduled to receive a new medication refill.*
INITIALS
Evaluations for purposes other than treatment
We are a mental health treatment facility and our providers enter into a relationship with patients for the purpose of offering treatment. As such, we do not do evaluations for the purposes of determining eligibility for social security disability, fitness for duty, nor do we comment on matters concerning child custody.*
INITIALS
Non-evidence based treatments
We do not endorse or prescribe the use of medical marijuana or emotional support animals.*
INITIALS
Payment
Payment, including insurance copayments and deductibles, must be provided at the time of service.*
INITIALS
If you have an outstanding balance of $100.00 or more, we will ask that a payment be made towards your balance before your next appointment.*
INITIALS
Please be aware that services provided may not be covered by your insurer, but you are ultimately responsible for payment of all services rendered. Any balance that remains outstanding for more than 90 days may be referred to a collections agency.*
INITIALS
We do require a credit card be stored on file for all commercially insured patients, your card will never be charged without your informed consent. *See Credit Card Policy for more details**
INITIALS
I have reviewed, understand and agree to all office policies set forth above.*

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Signature of Patient/Legal Guardian
Printed Name*
Date*

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES

Effective 01/2019
This notice describes how medical information about you may be used and disclosed and how you can get
access to this information. Please review it carefully.

If you have any questions about this Notice of Privacy Practices, please contact our office at
405-400-1152.

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and
some of our responsibilities to help you.

Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health
information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request.
We may charge a reasonable, cost-based fee.

Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us
how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a
different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations.
We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that
information for the purpose of payment or our operations with your health insurer. We will say “yes”
unless a law requires us to share that information.

Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior
to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care
operations, and certain other disclosures (such as any you asked us to make). We’ll provide one
accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within
12 months.

Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice
electronically. We will provide you with a paper copy promptly.

Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person
can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on
page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights
by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling
1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear
preference for how we share your information in the situations described below, talk to us. Tell us what you
want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share
your information if we believe it is in your best interest. We may also share your information when needed
to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?
We typically use or share your health information in the following ways.

Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when
necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the
public good, such as public health and research. We have to meet many conditions in the law before we can
share your information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health
and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective
services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a
subpoena.

Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of
your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in
writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you
change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about
you. The new notice will be available upon request.
Use and Disclosure of Health Information for Treatment and Payment

We may use or disclose health information in order to provide and coordinate your healthcare, or obtain payment for health care services.
I, (Patient or Legal Guardian if patient is a minor) Name* ,have reviewed, understand, and consent to the use and disclosure of health information for treatment and payment purposes. I also acknowledge that I have received a copy of the notice of privacy practices with the effective date of 01/2019.
Signature of patient/legal guardian if patient is a minor

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Should be Empty:

	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 bad might happen

	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, like you are a failure, or have let your family down
7. Trouble concentrating on things, such as reading or watching TV/videos
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 more than usual
9. Thoughts or hurting yourself or that you'd be better off dead

New Patient Questionnaire

Family Mental Health History

Outpatient Mental Health Treatment History

Mental Health Medication History

Inpatient Mental Health Treatment History

Developmental History

Medical History

Rating Scales

GAD-7

Patient Health Questionnaire (PHQ-9)

Social History

Consent for Text and Email

CONSENT TO OBTAIN PRESCRIPTION HISTORY

OFFICE POLICIES

Appointments

After-hours, Emergency and Holiday Coverage

Refills and Prescriptions

Evaluations for purposes other than treatment

Non-evidence based treatments

Payment

NOTICE OF PRIVACY PRACTICES

Use and Disclosure of Health Information for Treatment and Payment