Riddle Psychiatry Intake Form

Riddle Psychiatry Intake Form
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
What pronouns do you prefer that we use when talking about you?*
African AmericanAsianNative Hawaiian or Other Pacific IslanderWhiteOther
SingleDivorced / SeparatedMarriedWidowed
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Format: (000) 000-0000.
Cell Phone Number*
Format: (000) 000-0000.
Email
example@example.com
Preferred Point of Contact*
Emergency Contact Information:

In our outpatient psychiatry practice, an emergency is a situation where your safety, or the safety of others, s at immediate risk. Examples include suicidal thoughts or actions, threats of harm to self or others, severe changes in mental status, or a medical crisis during treatment. We may also contact your emergency contact if you are unreachable and we have a reasonable concern for your safety or wellbeing. In these situations, we will share only the minimum necessary information to help ensure your safety and arrange appropriate care.
Emergency Contact #1*

First NameLast Name
Emergency Contact Phone Number*
Format: (000) 000-0000.
Appointment InformationBilling InformationNo Information/ Contact for Emergency ONLYOther
Emergency Contact #2

First NameLast Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Appointment InformationBilling InformationNo Information/ Contact for Emergency ONLYOther
Full-timePart-timeNot EmployedRetiredSelf EmployedStudentActive Military Duty
If working, what is your occupation :
Primary Care Physician

First NameLast Name
Primary Care Physician Phone Number
Format: (000) 000-0000.
YesNo
Current Therapist / Counselor

First NameLast Name
Therapist's Phone Number
Format: (000) 000-0000.
Pharmacy Information: (Local Pharmacy)*

Pharmacy:

Street Address

CityState / Province

Postal/ Zip Code:
Pharmacy Phone Number:*
Format: (000) 000-0000.
Pharmacy Information #2: (Mail-Order Pharmacy)

Pharmacy:

Street Address

CityState / Province

Postal/ Zip Code:
Pharmacy Phone Number #2:
Format: (000) 000-0000.
Personal History
Patient (self)ParentFamily MemberLegal Caregver
Living AloneLiving with Spouse / PartnerLiving with Roomate(s)Living with ParentsOther
How many in your household, including yourself?
YesNo
List your children and their ages:
YesNo
List your siblings and their ages:
Please list the problem(s) which you are seeking help? *
AddictionConfusionHelplessMedication EffectsPhobiaADHDDepressionHopelessMemory ProblemSelf-InjuryIncreased / Decreased libidoHallucinationsConcentration/forgetfulnessAnger / TemperEnergy level increased / decreasedChange in appetiteImpulsivityObsession / OCDIncreased / Decreased irritabilityFatigueCrying spellsAnxietySuicidal ThoughtsGriefPanic AttacksTearfulnessBipolarParanoriaBinge EaingParkinson'sHallucinationsOther
YesNo
YesNo
When was the last time you had thoughts of dying?
How often do you have these thoughts?
On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?

1

2

3

4

5

6

7

8

9

10

1 is Weak, 10 is Strong

Rows	Yes	No
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Is there anything that would stop you from killing yourself?

DisabilityFamilyHousing ProblemsPeer / FriendshipsDivorceFinancial ProblemsLimited RecoursesSupport SystemEducation ProblemsHeath ProblemsMarriageWork IssuesHallucinationsOther
YesNo
YesNo
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.

Symptoms / Mood / Behavior

Rows	Rarely	Sometimes	Often	Always
Problems with eating:
Problems with sleep:
Physical Pain:
Digestive Problems:
Sadness:
Constant Worry/ Anxiety/ Fears:
Difficulty with Anger:

Support System:

Rows	Good	Fair	Poor
Overall Family Support
Friends:
Other (e.g. community, work, etc)

Medical History
Do you have any allergies? (If yes, please list them)*
Current Weight*
Current Height in inches*
List all current prescription medications and how often you take them*
ArthritisChronic PainLiver DiseaseStomach ProblemsBlood DisordersDiabetesLung Disease/ breathing problemsStokeBowel ProblemsGlaucoma / Vision ProblemsCancerHeart AttackSeizures / EpilepsyUlcerChest PainsHepatitisNoneOther
Past medical problems, nonpsychiatric hospitalization, or surgeries*
YesNo
YesNo
Exercise Level
YesNo
How much time each day do you exercise?
Psychiatric History:
YesNo
If yes, Please describe when, by whom, and nature of treatment
YesNo
If yes, Please describe when, by whom, and nature of treatment
Past Psychiatric Medications

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

Rows	Have you ever taken it?	Dates	Dosage	Side Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)

Other medications?
MethamphetamineCocaineStimulants (pills)HeroinLSD or HallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizer/sleeping pillsAlcoholEcstasyOther
How many caffeinated beverages do you drink a day?
Tobacco History
YesNo
How many packs per day?
How many years?
Family Psychiatric History
Bipolar disorderDepressionAnxietyAngerSuicideSchizophreniaPost-traumatic stressAlcoholabuseOther
Family Background and Childhood History:
YesNo
Where did you grow up?
YesNo
Highest grade completed?
Additional information you'd like for us to know
Signature*
Guardian Signature (if under age 18)

Insurance Information:

IT IS REQUIRED FOR YOU TO BRING A PHOTO ID AND YOUR INSURANCE CARD TO EVERY VISIT
Name*

First NameLast Name
Insured Date of Birth*

MonthDayYear
Date
Relationship to Patient:
Insurance Company Name:*
Id Number:*
Group Number:
YesNo
Please Upload a front and back copy of your insurance card here to ensure we are billing to the correct place:

Cancelof
I understand that my insurance company is billed as a courtesy by this office. This office DOES NOT offer benefit verification; it is the patient's responsibility to know what type of Mental Health coverage they have with their plan. If balances go unpaid by my insurance carrier or if I do not have coverage for Mental Health, it is my responsibility to pay the balances on my account. This office will provide patients with a Superbill to submit to their insurance company for reimbursement. Our office has 90 days from the date of service to submit claims to insurance companies. After 6 months of attempting to bill the insurance company without payment or response, I understand that the balance will become my responsibility. We will no longer submit claims after 6 months of non-payment.

OUR OFFICE DOES NOT ACCEPT ANY FORM OF MEDICAL ASSISTANCE OR STATE INSURANCE.

It is the patient's responsibility to keep their insurance information up to date with our office. We will attempt to contact the patient via phone call, email and paper mailing statements for updated insurance information; however, if attempts go unanswered, the balance will become the patient's responsibility. I understand that I am financially responsible for deductibles, co-payments, co-insurance, missed appointment fees, non-covered charges, and any balances not covered under a contractual agreement between Riddle Psychiatry and my insurance payer.
Yes
Self Pay Rates:
- Initial Evaluation $250
- 30 minute medication management: $125
- 31 minutes to 45 minutes medication management: $150
- 1 hour medication management: $200
- Follow up Talk Therapy only sessions w/ Betsy Stratton: $150
YesNoUnsure
Name

First NameLast Name
Insured Date of Birth

MonthDayYear
Date
Relationship to Patient:
Insurance Company Name:
ID Number:
Group Number:
Please note: if the patient does not have a secondary insurance, the patient is responsible for any approved balance remaining after the primary insurance pays. This also includes if a patient has a Medicaid/ State insurance plan beings we DO NOT accept that.
Yes
Payments and Billing:

Our office accepts payments in person by cahs, debit or credit cards. Effectiive September 2025, we will no longer accept personal checks as a form of payment.

If you choose to keep a credit card on file, you are authorizing Riddle Psychiatry to automatically charge your card for any amount due on your account, including copayments, fees, and outstanding balances.
Yes
I, full name* authorize Riddle Psychiatry, LC to bill my insurance company for charges incurred during the course of my treatment, to provide any information necessary to process my claims, and to collect payment. I authorize my insurance company to honor payments made directly to Riddle Psychiatry.
Signature*

HIPAA Patient Information

(Health Insurance Portability and Accountability Act)
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
By signing this form, I acknowledge and agree to the HIPAA policies of Riddle Psychiatry. I understand that disclosures of my protected health information (PHI) may be made by this practice in accordance with HIPAA regulations and that I have certain legal rights regarding my PHI.

I understand that all information given by me or my family to the treating clincian is confidential and will not be released without my written consent or that of my legal guardian, except under special circumstances as described in detail in the practice's Notice of Privacy Practice.

I further understand that I may authorize the release of information related to my treatment to another person, provider, or company by signing a Release of Information (ROI) form provided by Riddle Psychiatry.

Because Riddle Psychiatry is bound by HIPAA, we cannot provide any information regarding my treatment, account, appointment times, prescriptions, or any records to any person other than myself without my explicit consent.
Yes
Authorized Persons / Agencies for Information Release

Please list below the names, relationships, and contact numbers of any individuals or agencies you authorize us to share your information with. You may amend this list at any time by contacting the office.
Full Name

First NameLast Name
Relationship to Patient:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Full Name

First NameLast Name
Relationship to Patient:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Full Name

First NameLast Name
Relationship to Patient:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I understand that I may obtain a current copy of Riddle Psychiatry's Notice of Privacy Practices upon request.
Signature
Today's Date

MonthDayYear
Date

Patient Policy
Consent to Treatment:

I voluntarily consent to receive a mental health evaluation, diagnosis, and treatment at Riddle Psychiatry. Treatment may be provided by licensed therapist, medical doctors (MD), and psychiatric nurse practitioners (PMHNP).

Treatment may include but is not limited to:
- Psychotherapy (individual, family)
- Psychiatric evaluations, medication prescriptions, and management
- Psychological testing and assessment
- Telehealth sessions via secure video or phone
- Other services as recommended by my provider
I understand that:
- My provider will explain my diagnosis, treatment options and the risks/benefits of care
- I may withdraw consent at any time, but I should discuss this with my provider for safe care transitions
- My providers may share information with each other within Riddle Psychiatry to coordinate care
- Confidentiality will be maintained in accordance with HIPAA and state law, except when disclosure is required by law (e.g., danger to self/others, abuse reporting).
- Signing this form does ot authorize the release of my psychotherapy notes under HIPAA. Release of psychotherapy notes require a seperate, specific authorization and is at the provider's discretion
Yes
Payments & Missed Appointment Fees
- Payments and co-payments are due at the time of service unless prior arrangements are made. We accept debit cards, credit cards, and cash payments. Effective September 2025, we will no longer accept personal checks.
- We require at least 72 business hours’ notice for cancellations of initial evaluations to avoid the $150 missed appointment fee.
- Missed appointment fee for follow-up sessions is $75. Missed appointment fee for initial evaluations without 72 business hours’ notice is $150.
- For follow-up visits, cancellation must be made by 3:00 PM the business day before your appointment. Monday appointments must be cancelled by 3:00 PM on Friday.
- No-shows and late arrivals beyond 15 minutes will be considered a missed appointment and charged accordingly.
- This policy applies to both in-person and telehealth appointments. Refill requests may be denied if follow-up appointments are not kept. Patients who cancel or miss 3 appointments may be dismissed from the practice.
Yes
Telehealth Services:

Telehealth involves the use of secure, interactive audio/video or telephone technology for diagnosis, consultation, and treatment. We use Doximity, a HIPAA-compliant telehealth portal, to conduct these sessions. Your provider will initiate the session by sending a text, email, and/or calling your phone directly. After three attempts to reach you, if there is no response, the session will be considered missed. It will then be at the provider’s discretion whether future telehealth sessions can be scheduled.

I understand I have the right to refuse telehealth at any time. Telehealth may have limitations compared to in-person visits. All privacy protections apply to telehealth sessions.
Yes
Payments & Missed Appointment Fees
- Payments and co-payments are due at the time of service unless prior arrangements are made. We accept debit cards, credit cards, and cash payments. Effective September 2025, we will no longer accept personal checks.
- We require at least 72 business hours’ notice for cancellations of initial evaluations to avoid the $150 missed appointment fee.
- Missed appointment fee for follow-up sessions is $75. Missed appointment fee for initial evaluations without 72 business hours’ notice is $150.
- For follow-up visits, cancellation must be made by 3:00 PM the business day before your appointment. Monday appointments must be cancelled by 3:00 PM on Friday.
- No-shows and late arrivals beyond 15 minutes will be considered a missed appointment and charged accordingly.
- This policy applies to both in-person and telehealth appointments. Refill requests may be denied if follow-up appointments are not kept. Patients who cancel or miss 3 appointments may be dismissed from the practice.
Yes
Other Fees
- Returned check fee: $35.00
- Completed forms fee (Workers Compensation, Disability, FMLA, etc.): $50.00
Yes
HIPAA and Privacy Notice

I acknowledge that I have received or been offered a copy of Riddle Psychiatry's Notice of Privacy Practices. I understand that by signing any release of information, it does not authorize the release of psychotherapy notes as defined by HIPAA guidelines. Release of such notes is at the discretion of my provider.
Yes
Acknowledgment & Signature

I have read and understood all sections above and agree to abide by Riddle Psychiatry’s policies. I have had the opportunity to ask questions regarding my care and these policies.
Signature
Today's Date:

MonthDayYear
Date
Should be Empty:

Riddle Psychiatry Intake Form

Personal History

Medical History

Exercise Level

Psychiatric History:

Past Psychiatric Medications

Tobacco History

Family Psychiatric History

Family Background and Childhood History:

Insurance Information:

HIPAA Patient Information

Authorized Persons / Agencies for Information Release

Patient Policy