New Patient Inquiry Form

Patient Name*

First NameLast Name

Date of Birth*

Date

Current Age of Patient*

Legal Sex

Patient Email Address (ages 14+)*

example@example.com

Patient Phone Number (ages 14+)

Please enter a valid phone number.

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number (will be used for appointment reminders and text notifications)*

Please enter a valid phone number.

Name of Legal Guardian initiating care for patient (if applicable):

Legal Guardian Phone Number:

Please enter a valid phone number.

Legal Guardian Email Address:

example@example.com

IMPORTANT:

Legal guardian email address MUST BE DIFFERENT than patient's email address as the patient is over the age of 14. Both patient and legal guardian have to use seperate emails to set up accounts within our electronic health record system.

Legal Guardian Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Legal Guardian 2 (if applicable):

Legal Guardian 2 Phone Number (if applicable)

Please enter a valid phone number.

Legal Guardian 2 Email (if applicable)

example@example.com

Legal Guardian 2 Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If patient is under the age of 18, is there a custody agreement filed with the courts?*

YesNoN/A - Patient is over the age of 18

Please note: adolescents over the age of 14 may consent to their own mental health treatment in PA. However, if there is a court order of joint legal custody, then the consent of both parents is required. Therefore, we screen all minors for custodial arrangements. CBI requires a copy of the order to be provided to our office prior to scheduling. The custody order must be reviewed by our clinical director to determine who needs to consent for treatment for the minor. Please upload a copy of the custody agreement to continue initiating care for your child:*

Have you ever participated in services before at Cognitive Behavior Institute?*

YesNo

Please detail your previous treatment and providers at CBI:*

Are you currently involved with the judicial/court system or have pending or ongoing legal proceedings?*

YesNo

Is there a court order or other documentation we should be aware of related to pending or ongoing legal proceedings?*

YesNo

Please provide a copy of the documentation here (or it can be emailed to us: staff@cbipsychotherapy.org, or faxed to 724-299-8964)

How did you hear about Cognitive Behavior Institute?*

Name of Provider:*

For web search referrals: What search term did you use to find us?*

IMPORTANT: CBI is not in network with any Medicaid or State-funded insurance products at this time. Clients enrolled in a state-funded insurance plan will not be able to schedule with any licensed clinicians at CBI. With that being said, we do offer a pro-bono intern program that is available for clients with Medicaid. If you would rather receive a list of referrals or have additional questions, please contact our office directly 724-609-5002 or send us an email: staff@cbipsychotherapy.org*

I acknowledge

IMPORTANT: Please note CBI is unable to accept Workers Compensation claims.*

I acknowledge

IMPORTANT: Please note that CBI is unable to provide evaluations and/or services for pursuit of social security benefits.*

I acknowledge

IMPORTANT: If you are seeking completion of disability paperwork by a psychiatric provider at CBI, you must be an established patient with the psychiatric provider for a MINIMUM of 6 months.*

I acknowledge

Due to the overwhelming demand for behavioral health services in Pennsylvania, our services are limited and change very frequently. Please review our currently available services below and choose which services you're interested in:*

Psychiatry (Medication Management)Therapy/Counseling ServicesPsychological Testing & Evaluation

What type of therapy services are you seeking?*

Individual CounselingGroup Therapy: I'm interested in exploring what groups you have available.Family CounselingCouples/Marriage CounselingMarathon Intensive Couples Therapy with a certified Gottman therapist (SELF PAY ONLY)

In the event that we do not have an opening with a clinician in network with your insurance, we have other options available, including self pay clinicians and/or pro-bono master's-level interns. These clinicians are not able to accept insurance as they are not yet licensed.

I am open to self-pay clinicians if there are no immediate openings that accept my insurance.I am open to a master's-level intern for pro-bono therapy services.I would like to be added to the waitlist for a licensed clinician that accepts my insurance if no one is available.

For Group Therapy inquiries: was there a specific group at CBI that you are interested in? Or do you have an idea of what type of group you are looking for?

Name of Partner/Spouse for Couples/Marital Counseling:*

First NameLast Name

Partner/Spouse Date of Birth*

Date

Partner/Spouse Email Address:*

example@example.com

Partner/Spouse Phone Number*

Please enter a valid phone number.

Partner/Spouse Address (if different from identified patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please provide the following demographic information for family members that will be participating in family therapy:

	Name	Date of Birth	Phone Number	Email Address	Relationship to Patient
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5

All clients seeking psychological testing services should review the information on our website prior to completing this form.

Psychological testing is a specialized service that uses standardized assessment measures and procedures to gather data to inform diagnosis and treatment direction. Please make sure to refer to our website for additional information regarding psychological testing, including appropriate referrals for testing services, the psychological testing process, and approximate cost for psychological testing services.*

I have reviewed the psychological testing information on the website.

Please note that psychological testing services require a combination of virtual and IN-PERSON appointments at our Cranberry Twp location. Cranberry Twp is located north of Pittsburgh, PA in Butler County. By completing this form, you confirm ableness to travel to our Cranberry Twp office for psychological testing services.*

I confirm that I am able to travel to the Cranberry Twp office for in-person sessions that are required for psychological testing services.

Psychological testing often requires multiple appointments and can sometimes be an extensive process. Psychological testing is often appropriate for the following purposes: (1) Clarify diagnosis when there is uncertainty, (2) Data is needed to justify diagnosis, (3) Data is needed to guide treatment direction, and/or (4) Diagnosis and recommendations are needed for additional services. Oftentimes, testing is recommended by a patient's current provider. Was psychological testing recommended for you by any of the following?*

Are you currently receiving or have you ever received mental health treatment?*

YesNo

Please note: Clients seeking psychological testing services but have never seen a mental health provider before may not be approved for scheduling. Psychological testing is a specialized service and is typically not an appropriate first step to mental health treatment. Our psychologist will review your inquiry form and admin will reach out with a determination as to whether we can provide testing services at this time, or if you'll be referred to a therapist/psychiatrist for an initial assessment.*

I understand.

REQUIRED: Please have your referring provider or current mental health provider complete the form at the link below in order to proceed with psychological testing services. The first link is to a fillable electronic form while the second is a link to a PDF version of the form.

Electronic Psych Testing Provider Referral Form (or copy this link: https://hipaa.jotform.com/223486018038153)

PDF Psychological Testing Provider Referral Form

This form is required. Testing intakes will be scheduled once completed form is received.

The completed form can be sent back to CBI via email staff@cbipsychotherapy.org or via fax #724-299-8964.

Clinical Reasons for Psychological Testing (check all that apply)*

Differential psychiatric diagnosis (existing diagnosis present, seeking an alternative clinical opinion)Re-evaluation (previous testing completed and seeking updated testing) *A copy of past psychological testing must be providedPsychoeducational evaluation (learning concerns, school readiness, gifted) *Insurance may not cover educational testingDevelopmental (concerns for children aged 6 or under)Court-ordered/court-related evaluation. *A copy of court order must be provided to determine if we can scheduleOther

A copy of your past psychological testing must be provided for a variety of reasons: 1. Insurance may not cover if the same testing is done within 1 year period and 2. Validity of the results - if we provide testing services in too close of a period it could impact the results. We also use some tests that other psychologists may not use, so we review your previous report to see what was already done and what other tests we could provide.*

A copy of court order must be provided to determine if we can provide the evaluation that the court is looking for:*

Chief Complaint/Reason for Seeking Services (ex: Anxiety, Depression, ADHD, Trauma, etc.) question*

What type of insurance is the patient covered under?*

Commerical/Private Insurance PlanEmployee Assistance Program (EAP)Medicare/Medicare Advantage Insurance PlanMedicaid/State-funded Insurance (Access, UPMC For You, CCBH, Highmark Wholecare, Gateway, United Healthcare Community Plan, VBH, etc.)No insurance (Self Pay)

IMPORTANT:
Unfortuantely, CBI is not in network with any Medicaid or State-funded insurance products at this time. With that being said, we do offer pro-bono therapy services with a Master's level intern for clients enrolled in a Medicaid or State-funded plan.

Psychiatry/Medication Management services and Psychological Testing services are not available at CBI for clients enrolled in a Medicaid or State-funded plan.

If you would rather receive a list of referrals or have additional questions, please contact our office directly 724-609-5002 or send us an email: staff@cbipsychotherapy.org

Thank you.

Clients interested in pro-bono therapy services with a Master's level intern must commit to weekly sessions.*

I am interested in pro-bono therapy with a Master's level intern and can commit to weekly sessions.

Insurance Name*

Member ID Number*

Group Number (if applicable)

Policyholder Full Name*

First NameLast Name

Policyholder Date of Birth*

Date

Relationship to Patient*

IMPORTANT: Please note: CBI is NOT in network with any Medicaid/Medical Assistance insurance products, including but not limited to: CCBH, UPMC For You, United Community Plan, Aetna Better Health, Highmark Wholecare, Gateway, and VBH. Additionally, CBI is unable to accept Medicare/Medicaid DUAL plans.*

I understand CBI is not able to accept Medicaid/Medical Assistance

Please upload a copy of the front and back of your insurance card so that our administrative team can assist verifying your insurance coverage and confirm your mental health benefits:

Does the patient have secondary commercial/private insurance?*

YesNo

Are you currently taking any psychiatric medications? (includes any medications that treat psychiatric symptoms regardless of who is the prescriber)*

YesNo

If yes, please provide a list of all medications (as well as the doses) that you are currently taking:*

Please provide the name of your provider who is prescribing your current psychiatric medications:

First NameLast Name

The above provider is your:*

Primary Care Physician/PediatricianCurrent/Previous PsychiatristAnother Physician

Has the patient ever been admitted to a higher level of care?*

Yes - Residential Treatment ProgramYes - Inpatient Psychiatric HospitalizationYes - Partial Hospitalization Program (PHP)Yes - Intensive Outpatient Program (IOP)No

If yes to any of the above, please list each hospital/treatment along with the month and year:*

Has the patient had previous psychological testing completed with a licensed psychologist (PhD/PsyD)?*

YesNo

If yes, has the patient had previous psychological testing completed within the last 12 months?*

YesNo

Please upload a copy of your previous psychological testing report for our psychiatrists to review. If you do not have a copy of your psychological testing, a signed Release Form may be required for us to request the report prior to scheduling.

How many times in the past year have you had 5 or more drinks in a day?*

Alcohol Screening Questionnaire (AUDIT) Part 1*

	Never	Monthly or Less	2-4 times a month	2-3 times a week	4 or more times a week
How often do you have a drink containing alcohol?

Alcohol Screening Questionnaire (AUDIT) Part 2*

	0-2	3 or 4	5 or 6	7-9	10 +
How many drinks containing alcohol do you have on a typical day when you are drinking?

Alcohol Screening Questionnaire (AUDIT) Part 3*

	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often do you have 5 or more drinks on one occasion?
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was normally expected of you because of your drinking?
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before because of your drinking?

Alcohol Screening Questionnaire (AUDIT) Part 4*

	No	Yes, but not in the last year	Yes, in the last year
Have you or someone else been injured because of your drinking?
Has a relative, friend, doctor, or other health professional been concerned about your drinking or suggested you cut down?

AUDIT Score:

Have you ever been in treatment for an alcohol problem?*

NeverCurrentlyIn the past

How many times in the past year have you used a recreational drug or used a prescription medication for nonmedical reasons?*

How many times in the past year have you used marijuana?*

Within the last year, have you used cocaine, heroin, K2/spice, and/or hallucinogens (LSD, mushrooms, acid)?*

Multiple timesOnly onceNeverPast use more than a year ago

The following questions concern information about your possible involvement with drugs not including alcoholic beverages during the past 12 months.

"Drug abuse" refers to (1) the use of prescribed or over‐the‐counter drugs in excess of the directions, and (2) any nonmedical use of drugs.

The various classes of drugs may include cannabis (marijuana, hashish), solvents (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcoholic beverages.

Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.

Drug Abuse Screening Test, DAST-10 -- In the past 12 months...

	Yes	No
Have you used drugs other than those required for medical reasons?
Do you abuse more than one drug at a time?
Are you always able to stop abusing drugs when you want to? (If you've never used drugs, answer "yes")
Have you ever had blackouts or flashbacks as a result of drug use?
Do you ever feel bad or guilty about your drug use?
Does your spouse (or parents) ever complain about your involvement with drugs?
Have you neglected your family because of your use of drugs?
Have you engaged in illegal activities in order to obtain drugs?
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?

DAST-10 Score:

Are you currently receiving medical treatment from any of the specialists listed below? (Check all that apply)*

Name of Current PCP/Pediatrician:*

Does the patient have any CURRENT thoughts of wanting to hurt themselves?*

YesNo

How many times has the patient attempted to harm or kill themselves?*

Never123+

Has the patient ever been violent towards others?*

YesNo

Does the patient have active thoughts of wanting to hurt someone?*

YesNo

This form is not checked 24/7. If you are having thoughts of wanting to hurt yourself or someone else, please call your local mental health support hotline, such as 1-888-796-8226 (Resolve for Allegheny County, PA), the National Suicide Prevention Lifeline 988, call 911, or go to your nearest emergency room.*

I understand and will seek one of these or another service if needed.

A member of our administrative team will call you once we have received your information and are ready to schedule. When is the best time for a member of our staff to call and reach you to coordinate scheduling?*

Most CBI clinicians are treating clients virtually. Are virtual appointments okay?*

YesNo

If you prefer in-person visits, please indicate which office location(s) you are interested in:

Cranberry TwpMt. LebanonMonroeville

Do you have any specific preferences about your provider that you are matched up with?

Is there anything else you think we should know?

New Patient Inquiry Form

Demographic Information:

Acknowledgements:

Services Sought:

Insurance and Payment:

Additional Screening:

Patient Safety:

Appointment Preferences: