Evolve Psychiatry PAQ

1
Before You Begin

Please read carefully.

This form is best viewed on a desktop or an iPhone. If you have an Android, it is highly suggested you switch to a desktop.

If you wish to save your progress while on a desktop, click the Save button (with a disk icon) at the bottom of the screen and type in the email to which you want the incomplete submission sent to for continuing at a later time.

You may return to an earlier card by pressing the "Previous" button on the card.

Do NOT press "Back" on your browser since that will refresh the screen to the first card and delete all your information.

Do not try to scroll forward and skip cards. Incomplete submissions will not be uploaded to your patient chart causing delays in processing.

If you are having trouble completing the form, do NOT close the browser window. Instead call our office at 469-833-3360 for assistance.
2
Who is completing this questionnaire?* This field is required.The patient will eventually need to sign the treatment consent forms before the first appointment
Prospective adult patient
Spouse, friend, or caregiver of adult patient
Parent or guardian of a minor
Healthcare provider (Referral)
3
Treatment of Minors* This field is required.
4
If completing this form on behalf of another individual who will be the patient, please enter your own information here.Leave blank if you are the patient.
5
Patient Name* This field is required.This will be used for patient registration.
Enter FULL name as it appears on legal ID and health insurance card.
6
Address* This field is required.Please use the address of record on patient health insurance profile.
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
7
Patient Date of Birth* This field is required.This will be used for patient registration.
Date
Month
Day
Year
8
Contact Email* This field is required.This will be used for patient registration.
example@example.com
9
Contact Phone Number* This field is required.This will be used for patient registration.
Please enter a valid phone number.
10
How did you discover Evolve Psychiatry?* This field is required.
Recommended by a current patient
Previous patient of an Evolve Psychiatry expert
Referred by outside doctor
Referred by counselor
Referred by health insurance carrier
Hospital / facility discharge summary
Google search
Psychology Today
Health insurance carrier's website
Healthgrades.com
Zocdoc.com
Vitals.com
WebMD.com
Social media post
Online advertisement
Other
11
Were you referred to us by any of the following providers?Only select if the provider has discussed sending a referral for pre-verification
Please Select
Please Select
Texas Advanced Renal Health
Other
None
12
Cash Pay Option

Evolve Psychiatry offers a cash pay fee schedule that allows patients the following benefits:

Confidentiality of psychiatric diagnosis and records from insurance companies

Autonomy in selecting preferred providers, determining treatment options and progress without coverage restrictions

Expedited initial onboarding without delays due to insurance verification and prior authorizations

Treatment continuity unaffected by changes in insurance benefits and provider networks

Priority access to MD schedules

Priority appointment scheduling, refills, and referrals

Waived late cancellation fees

Financial savings

Allowing opt-out of expensive insurance coverage premiums

Waiving monthly visit requirement for controlled substances

Discounted ADHD assessment and documentation (forms, letters, and reports)

Superbills for potential reimbursement from health insurance company
13
Private Pay Fees

How much are cash appointments?

Initial consultations are $425.00; follow up appointments are $300.00

What are payment options?

Payment is due at time of service and can be made with any major credit card. We do not accept payment plans at this time.

What are rates for other services?

Please click here https://www.evolve-psychiatry.com/fees
14
How will you be billed for your care?* This field is required.See our cash pay fee schedule here.
Private Pay (Cash)Insurance
15
Legal Photo Identification* This field is required.Drivers License, State ID, School ID or Passport for any adult patient over the age of 18. For minors, please upload parent or policyholder's ID.
16
Name of Primary Insurance    Insurance *
Member ID    Member number *
Group Number    Group number
Policy Holder Name *
Policy holder D.O.B.    Date *
17
Primary Insurance Card* This field is required.Upload a clear picture of the FRONT of the card
18
Primary Insurance Card* This field is required.Upload a clear picture of the BACK of the card
19
Name of Secondary Insurance    Insurance
Member ID    Member number
Group Number    Group number
Policy Holder Name
Policy holder D.O.B.    Date
20
Secondary Insurance CardUpload a clear picture of the FRONT of the card
21
Secondary Insurance CardUpload a clear picture of the BACK of the card
22
What are the reasons for the inquiry?* This field is required.Select all that apply.
General mental health evaluation (no prior diagnosis or treatment)
Transitioning care for continuing medication management
Second opinion consultation (one-time visit)
Treatment for ADHD
Completion of forms or drafting a letter or report
Neuropsychological assessment for (Autism, Developmental Delay, Personality Testing, Firearms privileges), etc.
Treatment for substance dependency
Only seeking referrals for counseling/therapy
Other
23
ADHD Treatment Criteria* This field is required.
I have been on stimulants for at least one year within the state of Texas or California.
I have an official ADHD diagnosis by a neuropsychological evaluation.
I have records of at least one year of ADHD treatment by a past doctor (primary care doctor, psychiatrist, or pediatrician).
None of the above. I am interested in a private pay ADHD diagnostic evaluation.
24
ADHD Diagnostic Evaluation

The ADHD diagnostic evaluation includes a proprietary questionnaire to evaluate the presence and severity of ADHD symptoms, as well as their effects on different aspects of your life, such as academic and professional performance, social interactions, and daily activities.

Providers use your answers to carefully distinguish ADHD from other conditions with similar symptoms, offer in-depth education on the neurophysiology of the condition, and sound reasoning on whether to prioritize ADHD or any co-occurring challenges.

The out-of-pocket cost for a new diagnostic ADHD diagnostic assessment is $300.00.

You can find more information about the ADHD Diagnostic Evaluation here.
25
Do you wish to be considered for the supplemental ADHD diagnostic evaluation?* This field is required.
Yes, I will complete it along with my general intake forms after scheduling.
No, but I want to continue my inquiry for other reasons at this time.
26
Why do you need clinical documentation?* This field is required.Select all that apply.
FAA report
VA Disability Nexus letter
Work or school accommodations letter
Short Term Disability application
FMLA paperwork
Gender reassignment surgery requirement
Organ transplant surgery requirement
Spinal cord stimulator procedure requirement
Gastric bypass surgery requirement
Other
27
Neuropsychological AssessmentsWe do NOT currently offer neuropsychological assessments. Our providers do assess and manage the behavioral and emotional aspects of all these conditions providing we review existing medical records. You can find more information here
I would like to continue my inquiry for other reasons
Never mind. I will seek care elsewhere
28
What substance would you like assistance with quitting?* This field is required.Select all that apply.
Alcohol
Tobacco/Nicotine
Marijuana/THC
Cocaine
Methamphetamine
Heroin
Fentanyl
Inhalants
Prescription stimulants (Adderall, Ritalin, Vyvanse, Concerta)
Prescription opioids/painkillers (Percocet, Vicodin, Norco)
Prescription sedatives (Ambien, Lunesta, etc)
Prescription benzos (Xanax, Valium, Restoril, Ativan, Klonopin)
Hallucinogens (PCP, Ecstasy, mushrooms, etc)
29
List your frequency of usage in the past 2 months* This field is required.
30
What complications of quitting are you needing assistance with?* This field is required.Select all that apply.
Behavioral support
Cravings
General withdrawals (irritability, fatigue, nausea, headache)
Moderate withdrawals (palpitations, GI upset)
Severe withdrawals (hallucinations, seizures)
None
31
Case Complexity

Your case complexity will require a case review after your initial consultation to determine appropriateness for virtual care.
At any point during treatment, if our team determines you are better served in-person, we will transition your care to in-person visits, subject to provider availability.
Otherwise, our office will refer you to an external provider that may be more suitable for your care.
32
Do you wish to proceed with your submission?* This field is required.
YES, I would like to continueNO, I will seek care elsewhere
33
Briefly expand on your reason for consultation in your own words.* This field is required.(Example: "I'm looking for an evaluation for anxiety" or "I'm looking to continue meds with a new provider" or "I need medical clearance for a procedure.")
Huge
Large
Normal
Small
Ok
Ok
34
Past Psychiatric Diagnoses* This field is required.Select only conditions that are officially diagnosed by a healthcare provider and can be backed by clinical documentation.
Depression
Seasonal depression
Postpartum depression
PMDD
Bipolar 1 Disorder
Bipolar 2 Disorder
Generalized Anxiety
Social anxiety
OCD
Panic attacks
Agoraphobia
Separation anxiety
Compulsions / Addictions
Borderline Personality Disorder
Insomnia
Circadian Rhythm Disorder
PTSD / Nightmares
Eating Disorder
Anorexia
Bulimia
Binge Eating Disorder
Intellectual Developmental Disability
ADHD
Autism Spectrum
Dementia
Psychosis / Schizophrenia
Alcohol Abuse
Tobacco Use
None of the above"
35
Case Complexity

Your case complexity will require a case review after your initial consultation to determine appropriateness for virtual care.
At any point during treatment, if our team determines you are better served in-person, we will transition your care to in-person visits, subject to provider availability.
Otherwise, our office will refer you to an external provider that may be more suitable for your care.
36
Do you wish to proceed with your submission?* This field is required.
YES, I would like to continueNO, I will seek care elsewhere
37
Current Psychiatric Medications* This field is required.Example: Prozac 60mg daily, Buspar 10mg twice a day, etc. Click on the + sign to add more rows. Write "None" if applicable.
38
Do you anticipate needing to indefinitely continue or resume any of the following medications?* This field is required.Select all that apply.
alprazolam (Xanax®)
clonazepam (Klonopin®)
diazepam (Valium®)
lorazepam (Ativan®)
temazepam (Restoril®)
Eszopiclone (Lunesta)
Zaleplon (Sonata)
Zolpidem (Ambien)
Buprenorphine (Subutex)
Buprenorphine-naloxone (Suboxone/Zubsolv)
Other
None
39
Advisory on Management With Suboxone

Patients on Suboxone treatment:

Cannot be prescribed any other controlled substances, including but not limited to sedatives, opioids, stimulants, and benzodiazepines

Are limited to 30 day supply per prescription

Must schedule monthly visits for the duration of their treatment on Suboxone

Must abstain from concurrent cannabis useAre subject to random urine drug screens
40
Advisory on Management With Benzodiazepines

Patients on daily benzodiazepines:

Cannot be prescribed any other controlled substances, including but not limited to sedatives, opioids, stimulants, and other benzodiazepines

Are limited to 30 day supply per prescription

May remain on standing benzodiazepines for 2 to 3 months while until their medication regimen is optimized

Plan to taper their benzodiazepine usage until it is < 5x a month

Will be referred to in-person services, if unable to taper

Must abstain from concurrent cannabis use

Are subject to random urine drug screens
41
Case Complexity

Your case complexity will require a case review after your initial consultation to determine appropriateness for virtual care.
At any point during treatment, if our team determines you are better served in-person, we will transition your care to in-person visits, subject to provider availability.
Otherwise, our office will refer you to an external provider that may be more suitable for your care.
42
Do you wish to proceed with your submission?* This field is required.
YES, I would like to continueNO, I will seek care elsewhere
43
Please indicate if any of the following situations are applicable:* This field is required.Select all that apply.
Any history of higher levels of psychiatric care (Psych ER visit, hospital, IOP/PHP, residential program, rehab, detox)
Any history of self-harm, suicidal thoughts and/or actions
Age of 65+ years old
Medical conditions such as abnormal heart rhythm, seizures, pregnancy, kidney or liver disease, HIV, cancer, etc.
None of the above
44
Please explain your situation in more detail.* This field is required.
45
For any past higher level of care or suicidal thoughts/actions, when was the most recent occurrence?* This field is required.
Past 1 Week
Past 1 Month
Past 3 Months
Past 6 Months
Past 12 Months
Over 12 Months
46
Please briefly explain the circumstances and resolution of each incident.* This field is required.Please include months/dates, if possible.
47
Case Complexity

Your case complexity will require a case review after your initial consultation to determine appropriateness for virtual care.
At any point during treatment, if our team determines you are better served in-person, we will transition your care to in-person visits, subject to provider availability.
Otherwise, our office will refer you to an external provider that may be more suitable for your care.
48
Do you wish to proceed with your submission?* This field is required.
YES, I would like to continueNO, I will seek care elsewhere
49
Would you like to complete an optional section regarding your preferences?* This field is required.These include communication, visit, and provider preferences.
Yes, I want to customize my experience.
No thanks. I just want to finish.
50
Preferred Method of Communication
Text
E-mail
Phone
51
Opt-in to receive SMS messages from Evolve PsychiatrySMS messages are primarily used for appointment reminders and confirmations.
52
What is the best time of the day to contact you?
Anytime
Noon to 5pm
8am to Noon
5pm to 8pm
53
Desired Appointment Type
Soonest available
Telehealth (wait time: 1 to 2 weeks)
In Office only (wait time: 6 to 8 weeks)
54
Desired Appointment Time
Anytime
Weekdays 8am to 12pm
Weekdays 12pm to 3pm
Weekdays 3pm to 5pm
Weekdays 5pm to 7pm
Saturdays 12pm to 6pm
55
Language Preference
English
Spanish
Other
56
Bilingual Staff Limitations

Currently all our email communication, consent forms, and intake questionnaires are in English only.

Our team is conversational in Spanish, Hindi, Urdu, and Tagalog and can usually communicate directly without a translator. However, it is advisable to have a family member or friend assist you with completion of forms and interpretation during your medical appointment(s).

Having someone you trust who can help with communication can ensure that all your concerns and questions are accurately conveyed and understood.

For patient convenience, we now offer Saturday appointments for Spanish-speaking patients so that their loved ones can participate as well.
57
Would you be interested in an additional consultation for any of the following services?This answer is to strictly help us determine what treatment plan options you are open to discussing in your initial psychiatric consultation. You will not receiving any calls/emails if the service not part of your treatment plan.
Individual Therapist / Counselor
Group Therapy
Transcranial Magnetic Stimulation (TMS)
Ketamine Nasal Spray
IV Ketamine Therapy
None of the above
58
Thank you for your inquiry.

You may close out of this window without needing to submit this form.

Have a nice day.
59
Please provide a signature verifying that your submission is true to the best of your knowledge.* This field is required.
Clear
Should be Empty: