Child Intake Form - Fillable 2024

4720 Peachtree Industrial Blvd, Ste 4101, Berkeley Lake, GA 30092 (678) 861 6463

Welcome to our practice. The following information pertains to our practice policies. We look forward to working with you.

Your initial session is reserved for a thorough review of your history and current symptoms as well as medications. At the end of the session, we will discuss your diagnosis and treatment plan which may include talk therapy, medication management or a combination of both. We will provide you with a list of referrals for talk therapy. This office collaborates with your existing therapist for purposes of coordination of care. We do not provide talk therapy as part of our services. You may not be prescribed medications after your initial session if the provider does not deem them necessary. At the end of your first session, you may be referred out if our provider assesses that you will benefit from a higher or different level of care. This may include referral to Partial Hospital or Intensive Outpatient Programs or referral to a Community Service Board. Follow up appointments may be scheduled from 1 week to 4 months after your initial appointment based on the provider's recommendation. The frequency of follow up appointments may vary depending on response to medications, severity of illness and side effects. Medication management appointments are 15-30 minutes in length depending on the type of medication and ongoing issues that are being addressed. Please note that our office does not offer same day or crisis appointments. All paperwork is filled out in session with the patient and guardian present and at the discretion of our providers. This includes any school forms, FMLA, disability applications or any other form of documentation required for work/ school/ legal purposes. A $50 fee applies to each application being filled out. Our office does not fill out disability paperwork unless you have been an established patient with at least three visits with our provider.

Your appointment time is reserved for you. Therefore, if you are not able to keep your appointment time, please call as soon as possible to cancel or reschedule your appointment. If you do not provide at least 24 hours' notice of your cancelled appointment or if you fail to show for your appointment, you will be charged a no-show fee of $50. Contacting Us:

We will answer calls during business hours Monday-Friday. We will return phone calls within 24 hours with the exception of weekends and holidays. If you are experiencing an emergency and cannot wait to reach me, you should call 911 or go to the nearest emergency room. As soon as you are able to do so, please contact me to inform me of the situation. You can also reach the Georgia Crisis and Access Line at www.gcal.com. Please do not send us text messages or emails regarding your medications. Medication changes are best addressed in session with our providers.
We will bill your insurance company, but you will be asked to pay your co-pay or applicable balance in case you have not met your deductible. Payment will be required prior to the start of the session.

I understand that it is my financial responsibility for services provided until insurance deductible is met and any co-pay thereafter or if my insurance becomes inactive, but I continue to seek services from

Full payment is due at the time service is rendered. I acknowledge responsibility for all fees incurred including those for documentation, no shows, late cancellations, prescription refills. All balances 30 days past due will be deemed delinquent. Delinquent accounts must be paid in full before any future services will be provided. We reserve the right to send delinquent accounts to collections if needed. For minor children of divorced parents - Payment is expected from the parent(s) bringing the child for treatment irrespective of the divorce decree. We will release pertinent medical records only to the custodial parent. Parent who has signed financial responsibility paperwork will be held accountable for delinquent account. I have read and understand the above policies.
Patients Name
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Responsible Partys Name if patient indicate self
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Responsible Partys Signature

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Statement of Confidentiality: Under Georgia law communications between patients and psychiatrists are confidential, and under ordinary circumstances this privilege can be waived only by the patient. However, there are three clear exceptions in which a psychiatrist is legally and ethically bound to break confidentiality: (1)the patient is imminently dangerous to him or herself, (2) the patient is imminently dangerous to others and/ or has made specific threats to harm an identifiable third person, (3) actualor suspected incidents of child abuse. Although legally and ethically bound to break confidentiality under the aforementioned circumstances, I will not do so without attempting to discuss it with you first.

I have read and understand the above policies.
ParentGuardians Signature

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POINTS TO REMEMBER
1. Notify me if there are any significant changes in your psychiatric or medical condition, or if an outside provider changes your medication regimen. 2. Notify me if you suspect or know that you are pregnant or plan to become pregnant in the near future. Pregnancy will affect treatment recommendations. 3. If you feel you are at risk of hurting yourself or others, notify me immediately. If you feel you are an imminent risk and need immediate attention, call 911 or go to your nearest emergency

4. I welcome emails for non-urgent, administrative communication. Please note that the confidentiality of your email cannot be guaranteed. To discuss medical concerns, please call us at 678-861-6463 or email us at georgiabehavioralhealth@gmail.com to schedule an appointment. 5. If your medication makes you drowsy or slow your reaction time, please refrain from driving, and notify me. Also, notify me if your medication causes you other significant side effects. It is advised to not drink alcohol while taking psychiatric medications. 6. If you want to increase, decrease, or discontinue your medication regimen, please call us first. Medication management is a collaborative process. Changes without consultation from the provider could jeopardize your health and well-being and may interfere with our ability to work together and constitute as grounds for dismissal from our practice. 7. If you are seeking treatment with a service/therapy/emotional support animal, our practice does NOT provide these services and are NOT trained in these areas to prescribe to our patients. Also, we do not write any letters or documentaions for your animals, so please refer to professionals that are trained in these areas to receive your documentation. 8. Please remember to schedule your follow up appointment at the end of your session. Any medication refills called outside of your routinely scheduled appointment generate a $25 fee and are at the discretion of your provider. Controlled substances may not be called in without an appointment. Our office checks the Ga PDMP prior to prescribing controlled substances to stay compliant with Georgia law. 9. Following are grounds to terminate patients from our practice - a. 3 or more missed appointments in a 12-month period b. 3 or more cancellations with less than 24 hours' notice in a 12-month period C. Abuse of prescribed medications d. Positive urine drug screen for patients on controlled substances e. Rude, aggressive, inappropriate, or hostile behavior towards staff, providers, or other patients.

I have read and understand the preceding Points to Remember.
ParentGuardians Signature

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CONSENT FOR EVALUATION AND TREATMENT
I am legal guardian of (child's name) I hereby consent to psychiatric evaluation and treatment of him/her by Neha Khurana, MD.
childs name
and with full legal authority to consent to treatment.

Parents, Informed Consent & Divorce: If you share legal custody and your divorce decree notes that you must inform the other parent of health appointments, please note that you may be in violation of a court order if you fail to inform the other parent of your child receiving psychiatric services. Also note to provide consent for treatment of your child you must either have sole legal custody OR have shared legal custody, and if you have no legal custody you cannot provide consent for treatment. By signing below you are stating that you have the legal right to consent for this child. In the case of separation or divorce, any matter brought to my attention by either parent regarding the child may be revealed to the other parent. Matters which are brought to attention that are irrelevant to the child's welfare may be kept in confidence.
ParentGuardians Signature

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ParentGuardians Signature

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Medication and Prescription Policy

If Dr. Khurana is prescribing medications to you/ or your child as part of your treatment, regular follow up visits with her are required to closely monitor for efficacy, safety and potential side effects. Medication management requires working together to ensure the best response to medications. This includes maintaining scheduled follow up appointments.

You will be prescribed enough medication to last until your next follow-up appointment. Prescriptions will not be called in for patients that cancel/ or miss regularly scheduled medication follow-up appointments.

If you have to reschedule an appointment, please ensure that you schedule another appointment before you run out of medication. Our office will do our best to reschedule you, but keep in mind it may take several days to weeks to find an appointment that will be conducive to your schedule. It is your responsibility to make sure you do not run out of medicine.

Controlled Substances - Recognize that stimulant medications and Benzodiazepines are considered controlled substances and cannot be called in to or faxed to pharmacies. If you lose a prescription or your medication, it is at Dr. Khurana's discretion to issue a replacement. All controlled substances will have to go through the Georgia PRMP in accordance with the guidelines.

Dr. Khurana is committed to providing professional services of the highest quality and standards. In order to serve her patients efficiently and responsibly, she requires agreements be made as to the policies stated above. Patients are encouraged to ask questions before signing.

I have read the medication policies, understand, and agree with them.
Patients Signature

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Guardian if Minor
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NEW PATIENT INFORMATION SHEET
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Referred By
Name of Child
Age
Date of Birth

MonthDayYear
Date
MaleFemale
Address
City
State
Zip Code
Mothers Name
Fathers Name
Cell Phone
Cell Phone
Work Phone
Work Phone
Home Phone
Home Phone
Email
example@example.com
Email
example@example.com
Occupation
Occupation
Education
Education
If address is different from above, please list below:
Address
Address
City
City
State
Zip Code
State
Zip Code
Childs Legal Guardian (s)
Other specify
Relationship Status of Parents:
Please note any custodial or legal arrangements pertinent to the childs medical care
Name
Relationship to Patient
Phone
Work
Home
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Name of Pediatrician
Address

Address

Street Address Line 2

CityState

Zip Code
For purposes of continuity of care, may we contact your psychiatrist and/or therapist to let him/her know of your visit today?

YesNo
I give permission to Dr. Neha Khurana to send a general statement notifying my primary care physician of my visit today. The information sent will be used for coordination of care and will be limited to a brief description of the problem area and/or diagnosis, and a general outline of treatment.
Parent Guardians Signature

Clear
Date

MonthDayYear
Date
Pharmacy Information (If medications are prescribed):
Pharmacy Name
Phone
Address
City
State
Zip Code
Name of School (indicate if homeschooled)
Grade
Address

Address

Street Address Line 2

CityState

Zip
Please identify members of the child's household (Name, Age, Relationship, Living in Home - Yes or No), Occupation)
Please describe your reasons for seeking treatment at this time include when the problem started
How does your childs current problem impact family relationships or family functioning
Describe how your child gets along with other children Has your childs current problem affected peer relationships
Describe your childs experience and function in school Are there any problems
What are your goals for your childs treatment
What are your childs strengths andor unique qualities
What are your childs interests and hobbies
Has your child received other outpatient psychiatric care in the past Please provide name of prior providers including psychiatrists and therapists
Has your child ever been hospitalized for psychiatric reasons If so please provide dates and name of hospitals
Is there any family psychiatric history eg. bipolar disorder, anxiety, depression, schizophrenia, substance abuse, learning disorders, ADHD, autism? Please provide condition and which family relative.
Any family history of medical problems include seizures heart disease diabetes cancer liver disease stroke Parkinsons If your child is adopted please answer based on biological history if known
Is your child currently seeing a psychiatrist and/or therapist? Yes or No

YesNo
Name
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code
Phone
For purposes of continuity of care, may we contact your psychiatrist and/or therapist to let him/her know of your visit today?

YesNo
If Yes I
,give permission to Dr. Neha Khurana to send a general

statement notifying my primary care physician of my visit today. The information sent will be used for coordination of care and will be limited to a brief description of the problem area and/or diagnosis, and a general outline of treatment.
Parent Guardians Signature

Clear
Date

MonthDayYear
Date
How much did your child weight at birth?
Were there any developmental delays including speechwalkinggross or fine motor skills Describe
Any complications during pregnancy or delivery If so please describe
List any significant medical problems such as seizures head injuries accidents hospitalizations
Any history of chest pain, palpitations, murmurs, fainting, or post exercise symptoms? Please describe:
Allergies:
Any family history of early heart disease before age 30
Please note any other information that you think might be helpful for me to better understand your child and family
Current Medications - List any medications your child is currently taking including herbs/supplements (Dosage, Why Taking, Response)
Past Medications - List all psychiatric or neurological medications taken in the past (Dosage, Why Taken, Why Stopped)
CONSENT FOR RELEASE OF INFORMATION
Please complete for any providers that you would like me to collaborate with including therapists, primary care physicians and other specialists
Patient Name
Date of Birth

MonthDayYear
Date
I hereby authorize Dr. Neha Khurana to release

information from my medical records as described below to
Name
Phone Number
Fax
Email
example@example.com
The request and authorization apply only to the following information:

Medical History/Physical ExamDischarge SummaryPsychiatric Reports/TestsPsychiatric EvaluationsTreatment RecommendationsLaboratory/ReportsSummary of HospitalizationsPsychological ReportsMedicationsCourse of TreatmentConsultationsProgress NotesTeachers' ReportsSocial HistoryDevelopmental Hx
Other
Progress Notes Teachers' Reports Social History Developmental Hx

The purpose of the release of information is: The release will expire in 12 months unless specified by you. I understand that I can cancel this authorization at any time, except for action that has already been taken.
Signature of Patient 12 years and older

Clear
Date

MonthDayYear
Date
Signature of Guardian

Clear
Date

MonthDayYear
Date
4720 Peachtree Industrial Blvd, Ste 4101 Berkeley Lake, GA 30092 (678) 861 6463

Credit Card Authorization Form

24 Hour Cancellation Policy- If Dr. Khurana does not receive notice outside of 24 hours prior to the cancellation of your scheduled appointment you will be charged $50 for a no-show appointment. Signing this agreement authorizes our office to charge the card listed below for missed appointments.

Please complete the information below:

authorize Georgia Behavioral Health to charge my credit card (full name)

indicated below for payment of Psychiatric services for the following individual(s):
Print Full Name
Credit card will be charged after each appointment for services rendered. Authorization can be cancelled at any time with written consent.
BillingAddress
Phone
Email
example@example.com
SIGNATURE

Clear
DATE

MonthDayYear
Date
I authorize the above-named business to charge the credit card indicated in this authorization form according to the terms outlined above. | understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.
Account Type: Visa MasterCard Amex Discover
Card Number
Cardholder Name
Expiration Date

MonthDayYear
Date
CVV3digit number on back ofVisaMC 4 digits on front ofAMEX
Should be Empty:

POINTS TO REMEMBER

CONSENT FOR EVALUATION AND TREATMENT

NEW PATIENT INFORMATION SHEET

CONSENT FOR RELEASE OF INFORMATION