New Patient Registration Form

Patient Name:*

First NameLast Name

Patient Date Of Birth:*

MonthDayYear

Gender:*

FemaleMaleTransgenderOther

Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

Phone Number:*

Preferred Pharmacy: *

Please put pharmacy name and address.

Social Security Number*

For billing and prior authorizations for medications.

Marital Status:*

SingleMarriedDivorcedWidowed

Employment:*

Why Are You Seeking Treatment?*

Medication ManagementWeight LossSurgery ClearanceOther

How Were You Referred To The Practice? *

Name of PCP:

Name of Therapist/Counselor:

Have You Ever Attempted To Commit Suicide?*

YesNo

Do You Have Any Outstanding Warrants / illegal claims against you?*

YesNo

Do You Smoke? (Cigarettes, Vape, Marijuana)*

YesNo

Have You Ever Been Psychiatrically Hospitalized?*

YesNo

Do You Own A Firearm?*

YesNo

Upload A Picture Of The FRONT Of Your License *

If the patient is under 16 years old, the guardian of the patient must upload a picture of their license.

Are You Using Insurance Or Private Pay For Your Treatment?*

InsurancePrivate Pay

Primary Insurance Policy: *

Member ID Number: *

Are You The Policy Holder?*

YesNo

Name Of Policy Holder: *

First NameLast Name

Please Take A Picture Of The FRONT Of Your Insurance Card*

Please Take A Picture Of The BACK Of Your Insurance Card*

How Are They Related To You? *

Policy Holder Date Of Birth: *

Date

Terms*

Signature:*

General Anxiety Disorder Scale (GAD-7)

1.) Over the last two weeks, how often have you been bothered by the following problems? *

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
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 awful might happen

2.) If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult

Major Depressive Disorder Scale (PHQ-9)

1.) Over the last two weeks, how often have you been bothered by any of the following problems? Be as honest as you can. (Please check mark your answer for each row) *

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
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 of having little energy
5.) Poor appetite or overeating
6.) Feeling bad about yourself.. or that you are a failure or have let yourself or family down
7.) Trouble concentrating on things, such as reading the newspaper or watching television
8.) Moving or speaking so slowly that other people would have noticed. Or the opposite -- being so fidgety or restless that you have been moving around a lot more than usual
9.) Thoughts that you would be better off dead, or of hurting yourself

2.) If You checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult

Financial Policy Agreement:

Welcome to the medical practice of Envision Psychiatry. We want to inform you of our financial policies prior to your treatment to prevent any misunderstanding; it is our belief that addressing any financial concerns regarding your treatment upfront and as soon as possible is a critical part of your care.

If this agreement does not answer any questions you have concerning our financial policies, please do not hesitate to speak with our billing department at our practice.
To help us provide the best service possible, complete, accurate, and up-to-date insurance information is a necessity at each visit to the office.

- Insured patients: As a courtesy to you, our patient, we will submit claims to your primary, secondary and/or tertiary insurance plan on your behalf. Insurance coverage varies considerably from plan to plan and we must rely on you to inform us of the appropriate filing order and any special rules your plan requires.

- Your deductible, out of pocket, co-payment and co-insurance is due at the time of service unless other arrangements have been made in advance.

- Uninsured patients: Full payment is due at the time of service.

- We will verify your insurance coverage at every visit.

- There are fee's for any medical letters or documentation. For medical letters there is a $25 fee and for FMLA, and other documentation there is a fee of $50.

- Please be aware that there is a $70 no show / same day cancelation fee if you have more than two consecutive no/shows or same day cancelations and the card that you saved on file will be charged outside of our practice. Any unauthorized charges will be your responsibility.

- We accept American Express, Discover, Visa and MasterCard.

- Knowing your insurance benefits – including eligibility, covered benefits, and medically necessary procedures – is your responsibility. Please contact the customer service department at your insurance company for question you may have regarding your coverage.

- You are responsible for any charges not covered by your insurance plan.

Name Of Party That Is Financially Responsible For Payment: *

First NameLast Name

Please Take A Picture Of The FRONT Of Your Credit/Debit Card*

Please Take A Picture Of The BACK Of Your Credit/Debit Card*

By signing this consent, I agree to:

- Accept personal responsibility for all services rendered to me
- Authorize payment of medical benefits to Envision Psychiatry for any medical services rendered to me.
- Authorize Envision Psychiatry to release any information required in the course of my examination and treatment to my insurance company to assist them in paying my claims.

I Acknowledge And Consent To The Financial Policy And Agree: Signature:*

Office Policies:

Telehealth Platform

The provider currently sees patients through a secure, HIPAA-compliant portal such as simple practice or spruce health. All that is necessary to join a visit is an electronic device that has a camera and a microphone. Please connect to a stable internet connection. To receive telehealth services, you must be physically located in the State of New York at the time of the visit according to state laws.

Emergency Situations

If you are experiencing a crisis and the provider is unavailable to meet or be reached during or after business hours, it is recommended that you call 911 or go to your nearest emergency room. Voicemails and emails are considered non-urgent and will be returned within 1-2 business days, although usually addressed the same day.

Additionally, you may call 1888-NYC-WELL, or text well to 65173. This is free, confidential and available to all New Yorkers 24/7 in the event of a mental health crisis.

For Long Island residents: If you are having a crisis call 911 or go to your nearest emergency room. Additionally, you may contact DASH 631-952-3333. This is a program that helps individuals who are in crisis, due to substance use, mental illness.

Services Not offered

At this time, we cannot see patients who seek assistance for treatment of substance use disorders including for the purpose of rehabilitation, maintenance, or withdrawal ( methadone, Suboxone). It is recommended that patients who require specialized services seek appropriate outpatient substance use programs or visit your nearest Emergency room. Additionally, the prescriber does not prescribe ketamine or psychedelics for mental health reasons. In the State of New York, marijuana may be prescribed for medical and psychiatric conditions, but the prescriber is not registered with this program.

We do not offer worker’s compensation services or fill out disability claims.

Additionally, we do not offer forensic exams or psychiatric evaluations for legal matters including but not limited to court cases, immigration services, civil suits, criminal investigations, fitness for duty, child custody or divorce proceedings.

Controlled Substances and Prescriptions

Controlled substances such as stimulants for ADHD, benzodiazepines for anxiety ( Xanax, Ativan, clonazepam, valium) or hypnotics for sleep disorders are prescribed on an as needed basis. Controlled substances are considered high risks for abuse and may lead to physical and psychological dependence. Patient may become dependent or addicted when that was not their initial intention. As a result, controlled substances will only be prescribed when absolutely necessary.

The State of New York does not allow more than a 30-day supply of controlled substances or allow refill. If you are prescribed a controlled substance you will need to be seen every 4 weeks.

Once a prescription is filled, no prescription can be refilled earlier than seven days

If you take more than the required dosage of any controlled substance, please be aware that we cannot send early refills for prescriptions.

I Acknowledge and consent to the Office Policies and Agree: Signature:*