Mind And Soul Psychiatry Registration Form

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

Disclaimer: We do not do Autism Screening. We do not do long term disability.

Provider hours :See website Dovepsychiatry.com

Office Hours- See website

Due To Rising Costs, if not using INSURANCE, Intakes are $300 and follow-ups are $150 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 $90 cancellation fee.A 90$ hold is required to schedule an intake, and will be refunded the day after your intake or applied to a no show fee if office is not notified within 48 hours of cancellation. For follow ups, appointments must be cancelled prior to 48 hours.First no show is no charge. Second no show is a $90 cancellation fee and a discharge warning letter. After a third no-show, discharge may occur.

Patient Name

First NameLast Name

Date of Birth

Patients Date Of Birth

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Do you have a preference on how you would like to be contacted?

Do you consent / Opt-in to SMS text messages from Dove Psychiatry for Appointment reminders, and any updates that are related to your account?

Patient Gender

Other

How were you referred to the practice?

(Ex., Google, Provider, Individual)

Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment Status:

Type Of Treatment Seeking (Check As Many Options If It Pertains To You)

Other

Name of Pharmacy

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Picture Of Patient ID (If Under 17, it can be a school ID, passport, etc)

Therapist | Mental health Counselor | Psychologist

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Have you experienced any of the following? (Choose as many options if it pertains to you)

Do you own or have access to a firearm/weapon?

Have you ever been psychiatrically hospitalized?

Do you currently use any illicit substances or abuse any prescribed medications?

If you said yes, please state what you are currently using. Please be as honest as you can.

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 have health insurance coverage?

Are you the policy holder?

How is the policy holder related to you?

Other

Policy Holder Date Of Birth:

Date

Name Of Primary Policy Holder:

(Example: John Smith)

Name Of Insurance Policy:

Member ID Number:

Picture Of FRONT Of Insurance Card:

Picture Of BACK Of Insurance Card:

Picture Of Policy Holder License:

PART TWO:

I, undersigned, agree with Dove Psychiatry's office consent and policies..

Date Signed:

Date

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

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

Provider hours :See website

Office Hours- See website

Signature Of Acknowledgement For Payment Terms:

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

New Patient Registration Form

Patient Contact Information

Preferred Pharmacy Information

Other Provider Information

Patient Health Background

Office Consent & Policy Procedures:

Acknowledgment Of Policies & Procedures: