New Patient Screening

New Patient Screening
Patient Name (First name Last Name):*
Date of Birth (MM/DD/YYYY): *
CONSENT TO THE USE OF EMAIL AND OTHER FORMS OF COMMUNICATION

Correspondence for the Medical Practice and its new patient intake department is conducted using a HIPPA complaint encrypted email system. At times text and voicemail may also been used as a mean for communication. Correspondence can include Protected Health Information (PHI) and the Patient understands that there are limitations to confidentiality when using electronic mediums for communication.

The Medical Provider, Medical Practice, and staff of the Medical Practice are the only ones have access to the secured e-mail account that is also password protected on two levels; password protected to log onto the laptop or mobile device and password to get into the email server. The servers that are used are not open to the public and are also password protected. If Patient chooses to use non-encrypted or some other non-secured server/network or allow others to have access to their apps or technology, then Patient will not hold, The Medical Provider, Medical Practice, and employees of the Medical Practice liable for any breach of PHI. Patient will also notify Medical Practice if their e- mail account has been compromised and when the situation has been resolved. Patient is responsible for any PHI that is located on their technology or e-mail.
CONSENT TO THE USE OF EMAIL AND OTHER FORMS OF COMMUNICATION Your signature on this document indicates you authorize the Medical Practice, Morrison Clinic, and it's Billing Department known as CollaborateCOLLECT to contact you via e-mail, text, or phone and/or to respond to you via e-mail, text, or phone call, and that you understand that no form of electronically based communication is a completely secure form of communication, and will therefore not hold liable the Medical Provider for any unintentional breach in communication. You agree to release and hold harmless the Medical Practice, their Billing Department, and their Staff for any claim(s) you may have, past, present and future, arising from the use of e- mail, text messaging, or voice mails. This consent will remain in force until you provide written revocation to the Medical Practice. *
Your signature on this document indicates you authorize the use of e- mail,text, and/or phone*

Clear
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Restrictions

Morrison Clinic treats adults ages 18-64. This screening and intake must be completed by the person who is seeking to establish care at Morrison Clinic.
I certify I am between the ages of 18-64 and I am the person seeking to establish care at Morrison Clinic. *
Amy Morrison's Scope of Practice as a Physician Assistant
Amy Morrison is a Physician Assistant and is NOT a doctor. She practices under the supervision of a physician who determines and defines her scope of practice. Her supervising physician does not provide face to face direct patient care so it is important that you understand you will be under the care of a physician assistant who is required by law to only take on and continue to manage cases that are within the scope of practice.*
BILLING POLICY
In order to decrease the administrative burden for our low volume medical practice we require a working NON-debit credit card as a method of payment on each patient's billing account. This NON-debit credit card can be used as the primary method of payment or it can be put on file as a back up in the event that a debit or HSA card is declined due to low funds.*

Virtual Psychiatric Care
At this time Morrison Clinic is 100% virtual and it is important to us that we ensure that our virtual set up will be a good fit for you. Before we begin the new patient intake please answer a few questions to ensure that our virtual office is compatible to your needs.
Please login to the computer you will use to conduct your virtual visits, psychological testing, and other interactions with our clinic. It is highly recommended that you use an ethernet cable for fast and reliable internet. Open a new browser page and copy the web address below into the new browser page. Complete steps 1 through 4 and then return to this page.

https://morrisonclinic.com/steps-to-complete-a-week-prior-to-your-virtual-visit/
Go back to the results of your pre-call test and click on the words "Save this data as simple text" Copy the simple text and paste below. Use this text to answer the following questions.*
Were you able to verify your video camera worked in the pre-call test? *
Were you able to verify your audio worked in the pre-call test? *
Were you able to connect to all four OpenTok Servers in the pre-call test? *
Was your video and audio connectivity in the good or excellent range?*
Do you have access to a fast and reliable computer with a webcamera?*
Do you have a smart phone with a cellular data plan that you can use as a back up in the case that your computer or internet is not working?*

Psychological Testing

Virtual Psychological Testing is an appointment that is done virtually without the clinician, about a week prior to EACH one of your medical appointments. It is an important part of your treatment plan because it allows your clinician to obtain objective data that is used to gauge your response to medical treatment.
Psychological Testing is a separate appointment that occurs about a week prior to EACH medical appointment. It takes about 20 minutes to complete and you will receive multiple reminders of the date it is due. *
You will access psychological testing through Patient Fusion, your online medical chart with Morrison Clinic.
However, upon completion of this new patient intake screening patients who meet criteria to establish care at Morrison Clinic will be administered virtual psychological testing in a different format because you do not have access to Patient Fusion yet. *
New patient psychological testing is processed and billed upon your submission of this new patient intake. If you are not seen for a virtual psychiatric evaluation you will still be responsible for the out of pocket cost of psychological testing. This cost will be estimated for you before you submit this intake.*
TESTING COST TRANSPARENCY

Your insurance will likely determine that your psychological testing goes towards your deductible or that you owe a co-insurance or copay. It is best to estimate that your out of pocket costs will be the amount applied to your deductible so that you are not surprised by higher out of pocket costs than you expected. This will be explained in more details when you use our virtual insurance cost estimator. The next question is a brief summary of the highest out of pocket cost you would pay for psychological testing.
Which of the following methods of payment will you be using with Morrison Clinic?*

PAST PSYCHIATRIC HOSPITALIZATIONS: Have you ever been hospitalized over night at a psychiatric hospital or attended a rehab or intensive outpatient program?*
PAST SUICIDE ATTEMPTS: Have you ever attempted to execute a plan to end your life?*
PAST OR CURRENT PSYCHIATRIC DISABILITY: Are you currently or have you ever been on medical leave, short term disability, or long term disability for a psychiatric disorder? *
PSYCHOSIS: Are you currently or have you ever had problems with seeing or hearing things that other people don’t see or hear or believing things that other people do not believe?*
PSYCHOSIS SXS: Are you currently or have you ever had problems with seeing or hearing things that other people don’t see or hear or believing things that other people do not believe?*
PSYCHOSIS DX: Have you ever been diagnosed or suspected that you have Schizophrenia, Schizoaffective, paranoia, paranoid personality disorder, or psychosis? *
SUBSTANCE ABUSE AND ADDICTIONS: Do you currently or have you ever been addicted to alcohol, drugs, pornography, the internet, gaming, or gambling? If yes explain time span, substance used, and surround circumstances.*
PORNOGRAPHY, GAMING, INTERNET ABUSE: Do you have any current or past problems with the overuse of pornography, gambling, or gaming?*
CURRENT CANNABIS USE: Do you use marijuana or cannabis products more than once a week?*
BINGE DRINKING: Do you drink alcohol to the point of intoxication more than three times a month?*
CURRENT BENZO USE: Are you currently using benzodiazepine medication more than once a week ( examples include but are not limited to alprazolam, clonazepam, diazepam, lorazepam, flurazepam, triazolam, clorazepate. zolpidem, eszopiclone, temazepam)?*
WEEKLY ALCOHOL CONSUMPTIONS: Do you consume more than 10 alcoholic beverages in an average week?*
CURRENT OPIOD USE:Are you currently using opiod medication more than once a week (examples include but are not limited to tramadol, hydrocodone, codeine, oxycodone, hydromorphone, morphine, fentanyl, meperidine, methadone, suboxzone)? *

Additional Screening Questions
DISORDERED EATING TIMELINE: Have you struggled with purging, SEVERE restriction of calories, extreme use of laxative/diuretic/or diet pill use, or extreme overexercising due fear of weight gain in the LAST FIVE YEARS? Chose the best answer.*
PERSONALITY DISORDERS: Are you currently seeking treatment for, or have you ever been diagnosed with Borderline Personality Disorder, Narcissistic personality disorder, Antisocial personality disorder, Histrionic personality disorder, dependent personality disorder, or oppositional defiant disorder?*
PURSUING PSYCHIATRIC DISABILITY: Are you seeking disability or a leave from work at this time for a psychiatric disorder?*
PURSUING PSYCHIATRIC DISABILITY: Do you forsee you will be seeking disability or a leave from work in the future for a psychiatric disorder?*
CURRENT MEDICAL DISABILITY: Are you currently on long term disability for a NON psychiatric disorder?*
LEGAL CHARGES: Are you currently on probation for a legal charge or do you have a pending legal charge?*
HOMICIDAL IDEATION: Are you having any thoughts of wanting to commit homicide and end someone else’s life?*
SUICIDAL IDEATION: Are you having any thoughts of wanting to end your life or thoughts of wishing that you were dead?*
EMOTIONAL SUPPORT ANIMAL: Morrison Clinic does not conduct evaluations for treating psychiatric disorders with emotional support animals nor do the clinicians at Morrison Clinic write orders, letters, or prescriptions for emotional support animals.*
Are you seeking treatment for any of the following conditions: Alcohol abuse/dependence, Drug abuse/dependence, Eating Disorder, Addiction, Personality Disorder, Hallucinations, Psychosis, or Schizophrenia?*
Please answer the following questions with either True or False.
PSWV: In the past I have behaved in a manner that I or other people felt was harmful to business owners or their staff including but not limited to yelling, verbally abusing, threatening, manipulating, physical violence, and/or writing an unfair online review.*
PSWV 2: In the past I have behaved in a manner that I or others felt was harmful to my co-workers, strangers, friends, or a family members including but not limited to verbally abusing, threatening, undermining boundaries they set, physical violence, sexual violence, and/or manipulating.*
In the past, a medical provider or therapist has threatened to fire me from their practice or has fired me from their practice.*
I feel that paying a no show fee for missing an appointment or late cancelling an appointment is unfair.*
If my insurance were to deny payment on a medical claim, I would not feel obligated to pay the medical provider while I attempted to work out the problem with my medical insurance provider.*

Clinician's Scope of Practice

It has been determined that you fall within the scope of practice of Amy Morrison.
After submitting this form you will be routed to another form which must be completed in order for you to be scheduled for a new patient appointment.*

Physician Assistant Scope of Practice
Amy Morrison is a Physician Assistant and is NOT a doctor. She practices under the supervision of a physician who determines and defines her scope of practice. Her supervising physician does not provide face to face direct patient care so it is important that you understand you will be under the care of a physician assistant who is required by law to only take on and continue to manage cases that are within the scope of practice. *

Please note ONE of the following which you feel is THE MOST important to address:

Alcohol abuse/dependence, Anxiety, ADHD or concentration problems, Bipolar Disorder, Depression, Drug abuse/dependence, Eating Disorder, Hallucinations, Insomnia, Obsessions and/or compulsions, Panic attacks, Postpartum Depression, Posttraumatic Stress Disorder, Psychosis, Schizophrenia, Social Anxiety, Worry
The single most important thing I would like to address is:*
Please note ONE of the following which you feel is THE SECOND MOST important to address:

Alcohol abuse/dependence, Anxiety, ADHD or concentration problems, Bipolar Disorder, Depression, Drug abuse/dependence, Eating Disorder, Hallucinations, Insomnia, Obsessions and/or compulsions, Panic attacks, Postpartum Depression, Posttraumatic Stress Disorder, Psychosis, Schizophrenia, Social Anxiety, Worry
The second most important thing I would like to address is:*
Please note ONE of the following which you feel is THE THIRD MOST important to address:

Alcohol abuse/dependence, Anxiety, ADHD or concentration problems, Bipolar Disorder, Depression, Drug abuse/dependence, Eating Disorder, Hallucinations, Insomnia, Obsessions and/or compulsions, Panic attacks, Postpartum Depression, Posttraumatic Stress Disorder, Psychosis, Schizophrenia, Social Anxiety, Worry
The third most important thing I would like to address is:*
Amy Morrison is a Physician Assistant who practices under the supervision of a physician who defines and determines Amy's scope of practice. Unfortunately, the limitations to Amy's scope of practice do not allow her to take on your case. She recommends that you seek care at UT Southwestern, by calling 214-645-8500.*

Click the button labeled submit.
Should be Empty:

New Patient Screening

Restrictions

Amy Morrison's Scope of Practice as a Physician Assistant

BILLING POLICY

Virtual Psychiatric Care

At this time Morrison Clinic is 100% virtual and it is important to us that we ensure that our virtual set up will be a good fit for you. Before we begin the new patient intake please answer a few questions to ensure that our virtual office is compatible to your needs.

Psychological Testing

You will access psychological testing through Patient Fusion, your online medical chart with Morrison Clinic.

TESTING COST TRANSPARENCY

Additional Screening Questions

Please answer the following questions with either True or False.

Clinician's Scope of Practice

Physician Assistant Scope of Practice

Please note ONE of the following which you feel is THE MOST important to address:

Please note ONE of the following which you feel is THE SECOND MOST important to address:

Please note ONE of the following which you feel is THE THIRD MOST important to address:

Click the button labeled submit.