Mind And Soul Psychiatry Registration Form

New Patient Registration Form
Main: 631-881-4569 | Fax: 631-944-8000 | Email: dovepsychiatryshared@gmail.com

Disclaimer: We do not do ADHD or Autism Screening. Nor do we submit paperwork for long term disability.

Provider hours :See website Dovepsychiatry.com

Office Hours- See website

Due To Rising Costs, Intakes are $250 and follow-ups are $100 for a 15-30 minute session. This includes time spent to document, send your medications, and analyze any lab reports or previous documentation to document progress. If you do not want us to bill your insurance, you are responsible out of pocket for the difference not covered.

Please read- for intakes, cancellation fees less than 48 hours will result in a $100 cancellation fee. For follow ups, appointments must be cancelled prior to 48 hours.First no show is no charge. Second no show is a $80 cancellation fee and a discharge warning letter. After a third no-show, discharge may occur.
Patient Contact Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Patients Date Of Birth
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
EmailPhoneTextCall
YesNo
FemaleMaleNon-BinaryOther
Social Security Number (SSN)*
Reasons: Prior-Authorizations for Medications, Billing and Identity Purposes. If you don't feel comfortable with placing in your SSN, you can insert 0's instead.
How were you referred to the practice?*
(Ex., Google, Provider, Individual)
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status:*
Employment Status:*
Smoking Status:*
Genetic Background*
Education*
Psychiatric Medication ManagementSurgery ClearanceGenetic TestingOther
Preferred Pharmacy Information
Name of Pharmacy*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNoUnknownOther
If you chose 'yes' for any drug/food allergies, please list what it is here:*
Picture Of Patient ID (If Under 17, it can be a school ID, passport, etc)*

Cancelof
Other Provider Information
Primary Care Provider

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Therapist | Mental health Counselor | Psychologist

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Health Background
Sexual AbuseVerbal AbusePhysical AbuseNone Of the AboveI'd Rather Speak To My Provider About It
YesNo
YesNo
YesNo
Please give a brief detail of what occurred, and if you were hospitalized*
Please place in dates and hospital name (if known)
YesNo
If you said yes, please state what you are currently using. Please be as honest as you can.*
YesNo
Do you currently have/or been diagnosed with a PSYCHIATRIC diagnosis such as depression or anxiety? If so, what is it and please also add what medications you are currently on. *
(I.e., Bipolar Disorder, ADHD, etc.,) (I.e., Lithium, Adderall, Caplyta, etc.,)
Do you currently have/or been diagnosed with a MEDICAL diagnosis such as asthma or diabetes? If so, what is it and please also add what medications you are currently on. Did you get bloodwork within the year? *
(I.e., Congestive Heart Failure, COPD, etc.,) (I.e., Diuretic, Steroids, etc.,)
Health Insurance Information:

Due To Rising Costs, Intakes are $300 and follow-ups are $140 for a 15-30 minute session. This includes time spent to document, send your medications, and analyze any lab reports or previous documentation to document progress. If you do not want us to bill your insurance, you are responsible out of pocket for the difference not covered.
YesNo
YesNo
SpouseParentOther
Policy Holder Date Of Birth:*

MonthDayYear
Date
Name Of Primary Policy Holder: *
(Example: John Smith)
Name Of Insurance Policy:*
Member ID Number:*
Picture Of FRONT Of Insurance Card:*

Cancelof
Picture Of BACK Of Insurance Card:*

Cancelof
Picture Of Policy Holder License:*

Cancelof
Office Consent & Policy Procedures:
Mental Health Scales:

Based on NYS Law, you are required to answer these questions even if you feel that you do not experience any of these symptoms. As well as it is a helpful tool for your provider to construct a medication regimen that is suitable to you.
Not at allSeveral daysfour- five days out of seven daysDaily
Not at allseveral daysfour-five days out of seven daysdaily
Not at allseveral daysfour-five days out of seven daysdaily
Not at allSeveral DaysFour-five days out of Seven daysDaily
Not at allSeveral DaysFour-Five days out of seven daysDaily
Not at AllSeveral DaysFour-five days out of seven daysDaily
Not at allSeveral daysfour-five days out of seven daysDaily
GAD-7 (Generalized Anxiety Disorder Scale):
Not at allSeveral daysFour-five days out of seven daysDaily
Not at allSeveral daysFour-five days out of seven daysDaily
Not at allSeveral DaysFour-five days out of seven daysDaily
Not at allseveral daysFour-five out of seven daysDaily
MDQ Scale (Mood Disorder Questionnaire Scale):
PART ONE:

Check ( ✓) the answer that best applies to you.Please answer each question as best you can.*

Rows	Yes	No
1.) Has there ever been a period of time when you were not your usual self and…
2.) ...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
3.) ...you were so irritable that you shouted at people or started fights or arguments?
4.) ...you felt much more self-confident than usual?
5.) ...you got much less sleep than usual and found you didn’t really miss it?
6.) ...you were much more talkative or spoke faster than usual?
7.) ...your thoughts raced through your head or you couldn’t slow your mind down?
8.) ...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
9.) ...you had much more energy than usual?
10.) ...you were much more active or did many more things than usual?
11.) ...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
12.) ...you were much more interested in sex than usual?
13.) ...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
14.) ...spending money got you or your family in trouble?

YesNo
PART TWO:
No ProblemMinor ProblemModerate ProblemSerious Problem
YesNo
YesNo
Disclaimer: This questionnaire should be used as a starting point. It is not a substitute for a full medical evaluation. Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your doctor.
Acknowledgment Of Policies & Procedures:

Due To Rising Costs, Intakes are $300 and follow-ups are $140 for a 15-30 minute session. This includes time spent to document, send your medications, and analyze any lab reports or previous documentation to document progress. If you do not want us to bill your insurance, you are responsible out of pocket for the difference not covered.
YesNo
Date Signed:*

MonthDayYear
Date
Signature Of Acknowledgement To Dove Psychiatry, PLLC, office consent and policies: *

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Main: 631-881-4569 | Fax: 631-944-8000 | Email: dovepsychiatryshared@gmail.com

Disclaimer: We do not do ADHD or Autism Screening. Nor do we submit paperwork for long term disability.

Due To Rising Costs, Intakes are $250 and follow-ups are $100 for a 15-30 minute session. This includes time spent to document, send your medications, and analyze any lab reports or previous documentation to document progress. If you do not want us to bill your insurance, you are responsible out of pocket for the difference not covered.

Provider hours :See website

Office Hours- See website
Signature Of Acknowledgement For Payment Terms: *

Powered by Jotform SignClear
Main: 631-881-4569 | Fax: 631-944-8000 | Email: dovepsychiatryshared@gmail.com

Disclaimer: We do not do ADHD or Autism Screening. Nor do we submit paperwork for long term disability.

Provider hours :See website

Office Hours- See website dovepsychiatry.com
Should be Empty:

New Patient Registration Form

Patient Contact Information

Preferred Pharmacy Information

Other Provider Information

Patient Health Background

Health Insurance Information:

Office Consent & Policy Procedures:

Mental Health Scales:

GAD-7 (Generalized Anxiety Disorder Scale):

MDQ Scale (Mood Disorder Questionnaire Scale):

Acknowledgment Of Policies & Procedures: