Patient Inquiry Form

Patient Inquiry Form

Client Information
Legal First name *
Legal Last name *
Preferred name
Date of Birth *

Month Day Year
Date
Cell Phone *

Area Code Phone Number
Home Phone

Area Code Phone Number
Email *
example@example.com
Home Address (Please note: I am only licensed to see patients that live in Oregon or Washington) *

Street Address

Street Address Line 2

City State

Zip Code
Release of Information

(For current or past Therapist)

(Optional)
Client Name
Date of Birth

Month Day Year
Date
I authorize Dianna Harris, PsyD., PMHNP, to release information to and obtain information from:
Current or Past Therapist's Name
Current or Past Therapist's Address
City, State
Zip
Current or Past Therapist Phone Number

Area Code Phone Number
Current or Past Therapist Fax Number
Purpose of this request is to facilitate (check below):

Treatment and continuity of care
Type of information to be released (check below):

Medical and Mental Health Records
PROTECTED OR SENSITIVE INFORMATION: I understand that certain information cannot be released without specific authorization as required by State/Federal Law. By initialing, I authorize the release of the following protected or sensitive information:

REQUIRES INITIALS, do not x or check.
Mental Health Treatment
I understand that: I may cancel this authorization at any time by submitting a written request to Dianna Harris, PsyD, PMHNP, except where a disclosure has already been made in reliance on my prior authorization. x If the person of facility receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be re-disclosed FIf the authorized information is protected by Federal Confidentiality Rules 42CFR. Part 2. it may not be disclosed without my written consent unless otherwise provided for in the regulation. If the medical record information is not sent to another care provider, there may be a charge of the requested records.
Signature

Clear
Unless revoked in writing, this authorization expires 90 days after the termination of care.
Prescribing Practices
I do not prescribe any controlled substances, which include...

Benzodiazepines (xanax, klonopin, lorazepam, etc.)

Hypnotics (Ambien, Belsomra, Lunesta, Sonata, etc.).

Psychostimulants (Adderall, Ritalin, Vyvanse, etc.)
I acknowledge that Dianna Harris, PsyD, PMHNP, does not prescribe controlled substances.
Insurance Information
Name of Insurance Health Plan *
(Please note: I am In-Network with Moda, BCBS and Pacific Source. All other plans, including Cigna, Medicare, OHP, Providence and UHC, I am out of network.)
Member ID
(Please enter individual or family ID number, not Group ID number)
Font of Insurance Card

Browse Files
(Used for prescription benefits) Cancel of
Back of Insurance Card

Browse Files
(Used for prescription benefits) Cancel of
Clinical Information
What are the main issues you want to address?
Current Psychiatric Medications (name & dosage or N/A)
Past Psychiatric Medications (name & dosage or N/A)
Current and Past Treatment

In therapy now Taking psychiatric medication now In the hospital recently In therapy in the past Taken psychiatric medication in the past Attempted suicide in the past Hospitalized for psychiatric reasons in the past None of the above
What are your goals for treatment?
This service is provided as a way to make the process of getting accepted into a particular provider's practice more simple and efficient, but it can only be used if you agree that providing this information does not mean any doctor/therapist-patient/client relationship is being formed, and that no guarantee is provided that you will indeed be accepted into the practice. If you do not hear back or the provider informs you that he/she is notthe right fit for you, you are welcome to submit requests to other providers. If you are or believe you are experiencing a medical or psychiatric emergency. including suicidal or homicidal thinking. side effects to medication. or any other urgent or time-sensitive matter. do not use this service. Instead call 911 or go to your closest emergency room. If I do not agree. I will not submit this form.
Should be Empty:

Patient Inquiry Form

Prescribing Practices

Insurance Information

Clinical Information