Clinical Intake Forms

1
Which organization are you from?* This field is required.
Full Circle Therapy
Refresh Psychiatry
Full Life Comprehensive
Ellie Mental
Aspire Health Direct Primary Care
DM Health
Awaken Direct Primary Care
Weston Family Psychology
Bayview Therapy
Weston Psychcare
Inner Discovery Mental Health Services
Other
2
What is your name and/or Organization Name?* This field is required.
3
What is your contact information in case we cannot reach pt? email and phone number * This field is required.
4
Do you plan on continuing this case?* This field is required.
YESNO
5
What is the reason for referral? (PSY)* This field is required.
I think my client is a candidate for TMS or Spravato.
I need a second opinion.
My patient needs a new therapist.
My patient needs a new psychiatrist.
Other
6
What is the reason for the referral?* This field is required.
I think my client might benefit from medication. / My client needs a new psychiatric practitioner.
I think my client is a candidate for TMS or Spravato.
I need a second opinion.
I want the patient to get another evaluation for diagnoses.
My patient needs a new therapist.
7
Patient's Legal Name* This field is required.
First Name
Last Name
8
What name does the patient go by? * This field is required.
9
What type of insurance does the patient have?* This field is required.
Commercial
Medicare
No Insurance/I Plan on Self-Paying
Medicaid
10
We do not take any Medicaid Plans at this time.

Feel free to continue if you wish to self-pay for services.

Typical Self-Pay Rates:

$300 for One Hour Psychiatric Evaluation

$150 for 15-30 Minute Psychiatric Follow-Ups

$175 for Psychotherapy Appointments (1 hour) but we also have registered interns at lower rates if needed.
11
Who is the primary insurance provider?* This field is required.
12
Do they have a secondary insurance?* This field is required.
YESNO
13
Who is their secondary insurance provider?* This field is required.
14
Please note that we provide many of our services in-person. Evaluations are almost always in-person, and your providers may require you to do all subsequent visits in-person. Please make sure that the patient can reliably commute to our office in Cooper City, FL.* This field is required.
They canThey cannot
15
Patient Phone Number* This field is required.
Please enter a valid phone number.
16
Patient Email* This field is required.
example@example.com
17
Patient's Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
18
Patient's Date of Birth* This field is required.
19
Is the patient older than 65?
YESNO
20
What is the patient's diagnoses as of today?* This field is required.
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21
Based on your clinical experience, how serious is this case?* This field is required.
Mild - Patient is experiencing difficulties in their life but it is not too significant.
Moderate - Patient is experiencing significant difficulties that is interfering with their day-to-day functioning.
Severe - Patient is suffering to such an extent that their day-to-day functioning is severely impaired.
Very Severe - The patient's life and/or health is potentially at jeopardy if not addressed immediately.
22
Please contact Blue Umbrella's Practice Administrator (Melissa) immediately at (954) 758 - 4382.
DoneI can't do it
23
Has there ever been a diagnosis of (or do you suspect having) an eating disorder?* This field is required.
YESNOT TO MY KNOWLEDGE
24
Eating Disorders typically require specialized care. We recommend reaching out to National Eating Disorders Association for help on getting you connected to a provider (https://www.nationaleatingdisorders.org / (800) 931-2237). You may still fill out the forms, but our staff may relay this to you at time of intake as well.* This field is required.
I'll seek out care elsewhere and stop doing these forms.I still want you to see the patient.
25
Has there ever been a diagnosis of (or do you suspect having) a developmental disability? * This field is required.
YESNOT TO MY KNOWLEDGE
26
Can the patient accurately and verbally communicate their experiences with clinical staff?* This field is required.
YESNO
27
You may require specialized care. We recommend contacting insurance provider and seeking out specific services that specialize in developmental disabilities.* This field is required.
I'll seek out care elsewhere and stop doing these forms.I still want you to see the patient.
28
To your knowledge, does the patient abuse any substances? * This field is required.
YESNOT TO MY KNOWLEDGE
29
Please provide details below about this.* This field is required.
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30
Has the patient ever had an episode of psychosis?* This field is required.
YESNOT TO MY KNOWLEDGE
31
Please provide details below about this.* This field is required.
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32
Has the patient ever been hospitalized?* This field is required.
YESNO
33
Please provide details below about this.* This field is required.
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34
Please provide details of the case here.* This field is required.
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35
Please provide records or any relevant documentation here (Not Required but Encouraged)
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