• New Client Intake and Consents

    New Client Intake and Consents

  • Demographics

  • Format: (000) 000-0000.
  • Date of birth*
     - -
  • Gender*
  • Relationship to patient, if other than patient.
  • Reason Authorization if signed by Patient’s Representative:
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  • Today's date*
     - -

  • Psychiatric History

  • What is the primary purpose for seeking help? Select all that apply.
  • Have you ever been hospitalized for a psychiatric-mental health condition?*
  • Have you ever been diagnosed with a psychiatric-mental health condition by a medical provider?*
  • If yes, please select all that apply from the list below:
  • History of substance abuse (current or in the past)?*
  • If yes, please select all that apply:
  • History of development delay? (ex. delay in walking or talking as a toddler, IEP in school)*
  • Acknowledgements

    Acknowledgements

  • The purpose of your initial visit is to discuss your mental health needs, collect information and develop rapport. The initial visit does not guarantee the continuation of care at Complete Family Psychiatry. There is no guarantee that medication will be prescribed for you until after you present your case to the psychiatric-mental health provider and he/she determines that appropriate medications are necessary and/or a psychiatric treatment is needed under his/her care. Your medication history may be retreived for the purpose of medication decison-making. Please be advised that some medications can cause adverse reactions or side effects. By signing below, you understand that Complete Family Psychiatry will not be liable for any such unfavorable, unexpected, or inconvenient short or long term effects (adverse effects/side effects etc.). By signing below, you understand that Complete Family Psychiatry will not be liable for any such unfavorable, unexpected, or inconvenient short or long term effects (adverse effects/side effects etc.).

    I acknowledge that an AI-assisted documentation tool may be used during my visit to support accurate and efficient note-taking. I understand that this technology is used solely for documentation purposes and does not make medical decisions. All clinical decisions and care are provided and verified by my healthcare provider.

  • Do you acknowledge and agree with the above statement?*
  • Today's date
     - -
  • Authorizations/Consents

    Authorizations/Consents

  • I authorize payment of benefits to Complete Family Health, LLC dba Complete Family Psychiatry otherwise payable to the patient or guarantor. I also assign any and all rights to insurance coverage relative to this treatment, interpretation and/or examination.

    I give permission for Complete Family Health, LLC dba Complete Family Psychiatry to disclose any medical, psychiatric, alcohol and/or drug abuse information contained in my record to my insurance company for the purpose of review and authorization.

  • Do you acknowledge and agree with the above statement?*
  • Complete Family Psychiatry has permission to contact the patient or legal guardian via: (select all that apply)*
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  • Today's date*
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  • Should be Empty: