Mind Spa New Patient

Mind Spa New Patient
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Marital Status*

SingleMarriedWidowedDivorcedPartnered
Gender (Please select gender assigned at birth)*
Gender Preference (Only required if different than above)
Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Reminder Preference*
Employment Status*
Preferred Pharmacy Name/Location*
Add a photo for your patient profile (this must be an image of the patient face)
Add a picture of the Patient photo ID-this is required and must be government issued. This helps us in preventing insurance fraud. (IF patient is a minor, please upload a photo of the Responsible Party ID)
Responsible Party information (If Different from Patient) (Required for Minors)

Please disregard and move on to the next page if patient is the responsible party. In the instance that there is more than one Responsible Party please list both (i.e. mother & father)
Responsible Party Name 1

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Responsible Party Name 2

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance

If uninsured please write "Cash Pay" and move to the next page
Name of Primary Insurance*
Name of Primary Insurance Subscriber

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Relationship to Patient
Policy #/ ID
Group #
Please provide photo of the Insurance Card (FRONT)
Please provide a photo of Insurance Card (BACK)
Secondary Insurance

Only required if applicable-disregard and move on to the next page if you only have one insurance
Secondary Insurance Name
Name of Subscriber

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Relationship to Patient
Policy #/ ID
Group #
Please provide a photo of Insurance Card (FRONT)
Please provide a photo of Insurance Card (BACK)

Patient Consent to Policies and Procedures
BY SIGNING BELOW, I CERTIFY THAT I HAVE READ IN FULL, UNDERSTAND AND AGREE TO THE MIND SPA LLC POLICIES AND PROCEDURES.*

Powered by Jotform SignClear
Printed Name of Signee (if patient is a minor/unable to sign for themselves, please provide the name of the person legally able to sign on patient behalf)

First NameLast Name
MIND SPA REFILL REQUEST

In efforts to provide better quality of care for all of our patients, we have updated our medication refill policy.

You will need to leave a message if you have a controlled medication only. All other medications, you will need to request a refill through your pharmacy to send a request. Messages are checked throughout the day. Note: We are not open on weekends and major holidays, and on Fridays we do close early. Leave only one message as multiple messages do slow down the process. Same day requests are hard to fill due to a high volume of patients. Any delay could jeopardize your health; so we urge you to act promptly and request at least three days in advance.

Request to be filled when:

1.        You are due for a refill. Refills can only be given every 30 days.

2.        You have NOT missed an appointment. If you have missed an appointment you will need to schedule an appointment with a provider or walk-in during walk-in hours.

3.        If you are requesting a change of any kind you will need to make an appointment. Change of meds cannot be done over the phone or answered by leaving a message. Please schedule an appointment for this.

PLEASE NOTE: EVERY PATIENT IS DIFFERENT AND EACH PROVIDER HAS MADE AN INDIVIDUAL TREATMENT PLAN FOR EACH PATIENT. IT IS IMPORTANT TO COMPLY WITH THE TREATMENT PLAN YOU AND YOUR PROVIDER HAVE DISCUSSED.

Regarding the Mind Spa Payment Policy:

I understand and acknowledge the Mind Spa Payment Policy AND that I will be fully responsible for the fees not covered by my insurance. In issuance of a subpoena, regardless of who issues the subpoena, fees generated will be paid in advance.
Tobacco/Nicotine Use*

I currently use Tobacco/Nicotine ProductsI DO NOT currently use Tobacco/Nicotine Products
Acknowledgement of Privacy Practices

Please list any names or persons with whom MIND SPA can discuss your health care information, along with the relationship to patient. If you do not wish to have anyone on a Release of Information at this time please check the appropriate box. You may always add someone at a later date. *Parents and legal guardians are not required to be on a release of information. Please ensure parents and legal guardians are on the responsible party information so our office has those names.
Check this box if you opt-out of adding anyone to a release at this time.
Name

First NameLast Name
Relationship to Patient
Name

First NameLast Name
Relationship to Patient
Name

First NameLast Name
Relationship to Patient

	0-Hardly Ever	1-Much of the Time	2-Most of the Time	3-All of the Time
Low mood, sadness, feeling blah or down, depressed, just can’t be bothered
Feelings of worthlessness, hopelessness, letting people down. Not being a good person
Feeling tired, fatigued, low in energy, hard to get motivated, have to push to get things done, want to rest or lie down a lot
Feeling that life is not very much fun. Not feeling good when usually (before getting sick) would feel good, not getting as much pleasure from fun things as usual (before getting sick)
Feeling worried, nervous, panicky, tense, keyed up, anxious
Thoughts, plans or actions about suicide or self-harm

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself, or that you are a failure or have let yourself or your family down
Trouble concentrating on things such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or the opposite, being too fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or thoughts of hurting yourself

	YES	NO
… you felt so good or so hyper that other people thought you were not your normal self or you were so hyper you got into trouble?
…you were so irritable that you shouted at people or started fights or arguments?
…you felt much more self-confident than usual?
…you got much less sleep than usual and found you didn’t really miss it?
…you were much more talkative or spoke much faster than usual?
…thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
…you had much more energy than usual?
…you were much more active or did many more things than usual?
…you were much more social or outgoing, for example, you telephoned friends in the middle of the night?
…you were much more interested in sex than usual?
…you did things that were unusual for you or that other people might have thought were excessive, foolish or risky?
…spending money got you or your family into trouble?
If you checked YES to more than one of the above, have several of these ever happened during the same time period?
Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

Mind Spa New Patient

Responsible Party information (If Different from Patient) (Required for Minors)

Insurance

Secondary Insurance

Review of Systems Checklist

Patient Consent to Policies and Procedures

Acknowledgement of Privacy Practices

6-ITEM Kutcher Adolescent Depression Scale: KADS6

Patient Health Questionnaire (PHQ-9)

Mood Disorder Questionnaire

Social Screening