Adult Intake Questionnaire

Adult Intake Questionnaire

*18 years and older
Email*
example@example.com
Practice Approach and Expectations of Treatment (s) and Outcomes Statement

Mental health is unique and complex. Each diagnosis includes multiple symptoms, many of which overlap with other mental health diagnoses and the underlying cause for disorders is often due to multiple factors. For these reasons our practice focuses on an integrative approach which acknowledges that the mind and body are connected and that mental health disorders are a result of disruption in multiple body systems. This approach has an emphasis on lifestyle such as diet, physical health, environment, beliefs, behaviors, and spirituality as well as medications, only when needed, in order to achieve optimal functioning.

Now that we have informed you of our treatment approach, another important aspect of care is establishing realistic expectations of treatment(s) and outcomes. We have outlined below our expectations of clients as well as what you can expect from your treatment here at Psychiatric Wellness.

1. The field of Psychiatry is not a one size fits all approach. There are no quick fixes and most interventions and medications take a minimum of 1 month before we can begin evaluating for effectiveness.

2. While we can help decrease distress, provide support and resources, foster resilience, and teach healthy coping skills, we cannot change your life circumstances.

3. For some, optimal functioning may not be 100% symptom free.

4. Life stressors still occur, and it is normal and healthy to have emotional responses to stressful situations. Acute and temporary stress does not always require medication adjustments.

5. Willingness to change, in the form of lifestyle or outlook, is required in order to be successful; medication alone is often not sufficient to reach optimal functioning and wellbeing.

6. Providers and therapists provide tools in the form of medications, education, therapeutic techniques, advice, coping skills, and other forms. There is a level of accountability on your part, as the client, to communicate with providers and therapists and identify which tools you feel comfortable utilizing to create a mutually agreed upon treatment plan.

7. In between appointments, it is expected that you will follow the plan and utilize the tools you are given. If the plan is too difficult or not reasonable, your provider or therapist will work with you to make appropriate adjustments. We do not require perfection and understand real change takes time. Do not be afraid or ashamed to tell us if you are having difficulty with the current plan. Our goal is your success and we understand treatment plans need to be individualized.

8. While we try our best to identify the best approach on the first try, it often takes trials and adjustments over a period of time to find the most effective treatment plan. Do not be discouraged by this, the journey to emotional and mental health wellbeing is different for everyone and you do not have to do it alone. Psychiatric Wellness is dedicated to guiding you through this journey.

9. The most important aspect of treatment is patience; patience with yourself and your healthcare team.

By moving forward with your paperwork and completing this document, you will be indicating that you have read and understand the above practice approach and expectations of treatment(s) and outcomes statement.
I have read & understand all of the above information. I acknowledge that Psychiatric Wellness offers an integrative approach, unlike common traditional practices. Integrative treatment is person-centered care, based on holistic methods accompanied by medications, only if needed. The success of my treatment ultimately depends upon my willingness to make changes in my lifestyle, behaviors and overall mind-set. By selecting "I Agree" below you understand the above statements & believe the integrative treatment approach to be a good option for you.*

I Agree

Medications Policy
Psychiatric Wellness DOES NOT prescribe any stimulants (ie. Adderall, Vyvanse, Ritalin, Strattera, etc.) or benzodiazepines (ie. Valium, Xanax, Klonopin, Ativan, etc.) However, we do treat our clients diagnosed with anxiety and/or attention deficits using alternative treatment methods and medications.

By proceeding with this intake, you are acknowledging the fact that our providers will not prescribe these types of medications to any of our clients, as it is against clinic policy.

INITIAL EVALUATION AGREEMENT
Initial Consultation Fee (one-time payment).............. $200

**This fee is waived for SoonerCare clients or if documented income of equal to or below poverty line.**

We provide a personalized initial consultation where we get to learn your history and who you are, not just what issues you’re facing. Your first appointment with Psychiatric Wellness includes an Initial Consultation fee, due prior to scheduling your first appointment. This one-time fee covers the additional services provided to our new members:

Prior to your visit we will collect a patient portrait, in the form of an in-depth patient history, medical history and demographic information. Before your first appointment we perform an initial review of your information and create a pre-appointment plan of care as a means to maximize the use of our face-to-face time
On the date of service we perform a 60-90 minutes initial evaluation, where we stop, and give you time to tell your story. We create a comprehensive functional psychiatry prescription which may include* recommendations for nutraceuticals or supplements, nutritional guidelines, exercise advice, prescription medication management, and recommendations for additional laboratory evaluations.

*The cost of prescriptions, supplementation, laboratory evaluation is not included in the consultation fee.

Many of these additional services can and will be billed to your insurance provider, but and additional fees or services not covered will be due to the merchant, lab or provider rendering the service, which is
typically, a 3rd party.

*The initial consultation fee is required prior to scheduling your first appointment. This fee is non-refundable if unless initial consultation is canceled with more than 48 hours' notice.
By signing below, you agree that you have reviewed and understand the above information regarding initial consultation fees. *

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Client Rights Form
Initial Consultation Fee (one-time payment).............. $200

**This fee is waived for SoonerCare clients or if documented income of equal to or below poverty line.**

We provide a personalized initial consultation where we get to learn your history and who you are, not just what issues you’re facing. Your first appointment with Psychiatric Wellness includes an Initial Consultation fee, due prior to scheduling your first appointment. This one-time fee covers the additional services provided to our new members:

Prior to your visit we will collect a patient portrait, in the form of an in-depth patient history, medical history and demographic information. Before your first appointment we perform an initial review of your information and create a pre-appointment plan of care as a means to maximize the use of our face-to-face time
On the date of service we perform a 60-90 minutes initial evaluation, where we stop, and give you time to tell your story. We create a comprehensive functional psychiatry prescription which may include* recommendations for nutraceuticals or supplements, nutritional guidelines, exercise advice, prescription medication management, and recommendations for additional laboratory evaluations.

*The cost of prescriptions, supplementation, laboratory evaluation is not included in the consultation fee.

Many of these additional services can and will be billed to your insurance provider, but and additional fees or services not covered will be due to the merchant, lab or provider rendering the service, which is
typically, a 3rd party.

*The initial consultation fee is required prior to scheduling your first appointment. This fee is non-refundable if unless initial consultation is canceled with more than 48 hours' notice.
Signature of individual or legal representative required below. (e-signature - type full name)*

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Between-Visits Communication Policy Form
Between-Visits Communication Policy

Our providers often will communicate directly with clients after they have had their first visit via text or phone in between visits. This is mostly utilized for issues with prescription refills or short questions for which communication is free.

However, if a conversation about a more extensive such as a change to the treatment plan, ex: trying a new medication or wanting to discuss FMLA paperwork, then you will be charged for a phone visit. Sometimes insurance will pay for this and sometimes not but you will be ultimately responsible to make sure payment is received. Charges for these visits vary depending on the amount of time needed during the discussion and range from $40 to $100 (ex: a 7 minute discussion versus a 30 minute discussion). If longer than thirty minutes is needed, then an appointment needs to be scheduled.

Thanks,

Elisabeth Mustachia, APRN, PMHNP-BC
Signature of individual or legal representative required below. (e-signature - type full name)*

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Notice of Privacy Practices
1. Your medical records are used to provide treatment, bill and receive payments, and
conduct healthcare operations. Examples of these activities include but not limited to
review of treatment records to ensure appropriate care, electronic or mail delivery of
billing for treatment to you or other authorized payers, appointment reminder telephone
calls, and records review to ensure completeness and quality of care. Use and
disclosure of medical records is limited to the internal used outlined above except
required by law or authorized by the patient or legal

2. Federal and State laws require abuse, neglect, domestic violence and threats to be
reported to social services or other protective agencies. If such reports are made, they
will be disclosed to you or your legal representative unless disclosure increases risk of
further

3. Disclosed information will be limited to the minimum necessary. You may request an
account for any uses or disclosures other than those described in Sections 1 and
Sections 2.

4. You, or your legal representative, may request your records to be disclosed to yourself
or any other entity. Your request must be made in writing, clearly identify the person
authorized to request the release, specify the information you want disclosed, the name
and address of the entity you want the information released to, purpose and the
expiration date of the authorization. Any authorization provided may be revoked in
writing at any time. Psychotherapy notes are part of your medical records. We have 30
days to respond to a disclosure request and 60 days if the records is stored off site.

5. You may request corrections to your records.

6. A request for disclosure may be denied under the following circumstances: disclosure
would likely endanger the life or physical safety of you or another person, requested
information references other persons, except another healthcare provider, or if released
to a legal representative would likely result in harm.

7. If a request for disclosure is denied for reasons outlined in Section 6, you or your legal
representative may request review of the denial. A review will be conducted by another
licensed healthcare provider appointed by the original reviewer, who was not involved in
the original decision to deny access. A review will be concluded within 30 days.

8. You may request that we restrict uses and disclosures outlined in Section 1. However,
we are not required to agree to the restrictions. If an agreement is made to restrict use or
disclosure, we will be bound by such restriction until revoked by you or your legal
representative orally or in writing except when disclosure is required by law or in an
emergency. We may also revoke such restrictions, but information gathered while
required by law or in an emergency. We may also revoke such restrictions, but
information gathered while the restriction was in place will remain restricted by such an
agreement.

9. If you wish to complain about privacy related issues you may contact the Secretary of
the Department of Health and Human Services, Hubert H. Humphrey Building, 200
Independence Avenue SW, Washington DC, 20201. In any case there will not be any
retaliation against you or your legal representative for filing a complaint.

10. This agreement may be modified or amended as required by law or in the course of
health care operations.
I HAVE READ AND UNDERSTOOD THIS PRIVACY NOTICE AND MY RIGHTS CONCERNING USE AND DISCLOSURE OF PROTECTED HEALTH CARE INFORMATION.*

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EMAIL & TEXT COMMUNICATION CONSENT
I hereby consent and state my preference to have my provider and other staff at Psychiatric Wellness APRN-CNP PLLC communicate with me by email or standard SMS messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing.

I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my medical care might be intercepted and read by a third party.
Signature of individual or legal representative required below.*

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TELEHEALTH CONSENT FORM
1. I understand that at times video conferencing may be a viable form of treatment my therapist and I may discuss to promote continuity of care when I cannot physically be present in my therapist’s office due to several factors, including but not limited to: travel for work, recovering from an illness and not being able to travel, lack of access to transportation to the office, return to college, when weather advisories that make it unsafe to travel etc.
2. I understand that video conferencing is an option in which my therapist and I may use the internet on various devices, computer, tablet, phone, and will be able to see and hear each other and interact in real time to engage in psychotherapy.
3. I understand that the policy at Psychiatric Wellness APRN-CNP PLLC is to use platforms like Doxy.me whenever possible. It is encrypted to the federal standard, are HIPAA compatible and have signed a HIPAA Business Associate Agreement-attesting to HIPAA compliance. This platform is responsible for keeping any videoconferencing confidential and secure. Skype, FaceTime and other platforms are not as secure and there is a risk that private healthcare information may be breeched.
4. I understand that when I am engaged in telehealth psychotherapy, it is my responsibility to choose a secure location to ensure that family, friends, employers, co-workers, strangers or hackers cannot overhear my communications or have access to the technology or devices I am using.
5. I understand that, on my end, it is my responsibility to make sure that I am using a private and encrypted WIFI, (never a public WIFI) and that my devices have protections like firewalls, antivirus software and are password protected. I understand that my therapist is using the same standards on their devices to protect my privacy and confidentiality.
6. I understand that my therapist may only use Telehealth in states where they are licensed even though I may be in other locations. For example, if my therapist is only licensed in Michigan, they must transmit from Michigan and not from some other location they may be visiting.
7. I understand that most insurances now cover some form of telemedicine and that my therapist will have my benefits checked as a courtesy, but it is, ultimately, my responsibility to know whether or not my insurance company covers telemedicine sessions.
8. I understand there may be risks to telehealth psychotherapy, including but not limited to: poor internet connections, technical difficulties, power failures in the middle of a session, etc.
9. I understand that if there is a loss of transmission, my therapist will call me on the phone to complete the session. Phone sessions are not covered by insurance and there may be a private fee assessed for any part of a session that has to be completed via phone.
10. I understand that I can discontinue telehealth psychotherapy sessions and revoke this authorization at any time without affecting my right to future care or treatment. I also understand that my therapist has the right to discontinue telehealth sessions at any time if it becomes apparent that face-to-face treatment with the therapist would be more appropriate. I also understand that I may be referred to a therapist in my area if my therapist feels that this would be more beneficial to me.
11. I understand that I may benefit from telehealth psychotherapy sessions, but that results cannot be guaranteed nor assured.
12. I understand that this informed consent for telehealth psychotherapy is only in addition to my Informed Consent for Psychotherapy and does not replace it any way.
13. By signing this form, I certify: a. That I have read or have had this form read and/or had this form explained to me b. That I fully understand the risks and benefits of telehealth psychotherapy c. That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
Signature of individual or legal representative required below. *

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ETHICAL RESPONSIBILITY OF PROVIDERS
Ethical Responsibility in Service Delivery

• Counselors and other health care providers respect diversity and must not discriminate against consumers for any reason.

• Counselors and other health care providers must make every effort to avoid dual relationships with consumers.

• Counselors and other health care providers must not engage in any type of sexual intimacy with consumers.

• Counselors and other providers must take steps to protect consumers from trauma resulting from interactions during group work.

• Counselors and other providers must terminate any counseling relationship if it is determined that they are unable to be of assistance.

• Counselors and other providers must keep information related to counseling services confidential, except in very specific circumstances as outlined in Rights of Persons Served.

• Counselors and other providers must not disclose information about one family member in counseling to another family member without prior consent.

• Counselors, other providers and staff must maintain confidentiality with all records at all times.

• Counselors and other providers must obtain permission before recording sessions or transferring records.

• Counselors and other providers must not engage in sexual harassment or receive any personal gains, goods, gifts, or services.

• Counselors and other providers must communicate to group members that confidentiality cannot be guaranteed in group work.
Signature of individual or legal representative required below.*

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EQUIPMENT NEEDED FOR TELEHEALTH CONSENT
Equipment Needed for Telehealth Visits

Please note that if you are receiving medications and doing visits via telehealth you will need the following:

(1) A working electronic blood pressure cuff

(2) A working weight scale.

By signing this form you agree that you will have this equipment in place prior to your first visit.
Signature of individual or legal representative required below.*

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CLINICAL POLICIES
APPOINTMENTS
Appointments for medication sessions are required at least every three months for continuity of care and for patient monitoring. If medication adjustments are needed, appointments are dictated at the discretion of the provider. NEW medications are not prescribed without being seen due to the potential complexity of the medication, need for consent and thorough discussion and understanding of the risks and benefits of use. If prescribed a new medication, please know that you will follow-up at two weeks and at one month after starting the new medication or sooner at the discretion of the provider.
MEDICATION REFILLS
All prescription requests should be handled during scheduled office appointments. In extreme cases, refills will be handled within 3-5 business days (not including weekends or holidays) by email at officemanager@psychiatricwellness.org. Please keep up with your supply of medication to avoid running out. We are not equipped to handle emergent needs, so please plan accordingly.
CONTROLLED SUBSTANCES
Our clinic does not prescribe any benzodiazepines or other controlled substances. It is the patient’s responsibility to seek care at the nearest Emergency Room if experiencing symptoms of withdrawal.
MEDICAL LETTERS
Extended documentation including FMLA/disability paperwork are billed at $50.00-$150.00. If you require simple school/work letters for absences there is no a charge. Payments for documentation should be done at our office at time of request. Once the payment is complete, the document will be released. Please note that a Release of Information (ROI) is also required. ROIs are available at the time of your appointment or from our website.
TELEPHONE CALLS AND EMAILS
**PLEASE RECOGNIZE THAT WE ARE NOT AN EMERGENT OR CRISIS CARE FACILITY**
We typically return calls or emails within 24-48 hours during business hours. Please do not email with questions about treatment as these must be addressed during appointments.
DISCHARGE FROM THE CLINIC
Psychiatric Wellness APRN-CNP PLLC reserves the right to discharge any patient from treatment if concerns about the safety of the patient or provider occur. Examples include:
• Taking more or less medication than prescribed.
• Chronic lateness, no-shows, or cancellations without giving 24-hour advanced notice.
• Abuse of email or telephone calls (emails are only for brief communication). New medication(s) will NOT be filled via email or phone calls.
• Threatening behavior or harassing staff in any way (argumentative, verbally, physically, etc.).
• Not completing labs, recommended outpatient therapy, or other modalities and treatments as ordered.
• Abuse of the controlled substance policy. If you are discharged from our care, you will be provided with appropriate referrals upon request as well as a 30-day refill to give you enough time to find a new provider.
I have read through Psychiatric Wellness APRN-CNP PLLCs Clinic Policy forms and have been given a copy. I agree to follow the policies as set forth in the policy. I understand that if I do not follow certain guidelines as instructed in the policy that I may risk being removed from the care of Psychiatric Wellness APRN-CNP PLLC.
Signature of individual or legal representative required below.*

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CONSENT FOR TREATMENT
The undersigned patient or responsible party (parent, legal guardian or conservator), consents to, and authorizes services by Psychiatric Wellness APRN-CNP PLLC. These services may include psychotherapy, medications, laboratory tests, diagnostic procedures, and other appropriate alternative therapies.
The undersigned understands that he/she has the right to:

1. Be informed of and participate in the selection of treatment modalities.
2. Receive a copy of this consent.
3. Withdraw this consent at any time.
Signature of individual or legal representative required below.*

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FINANCIAL POLICY
Thank you for choosing Psychiatric Wellness APRN-CNP PLLC for your mental health care. This policy has been put in place to ensure that financial payments are recovered to allow us to continue to provide our patients with quality care. It is important that we work together to assure that payment for service is simple and straightforward. We will be happy to discuss these policies with you. Please carefully read each statement and sign below:

1. I understand that if I do not have my insurance card, referral, co-payment, deductible, and/or coinsurance, that my appointment may be rescheduled until such time that I can provide the required documents or payments.

2. I understand I am financially responsible for any copayments, deductibles, coinsurance and all charges, which are not covered by my insurance. I understand that verification of coverage is not a guarantee of payment of benefits. My insurance company determines benefit payments. I understand I will be responsible for the portion not covered by my insurance. I understand I am responsible for knowing my financial responsibility for all tests and procedures.

3. I understand that if I am unable to make a scheduled appointment I need to contact the office at least 24 hours prior to my scheduled appointment. A $150 FEE WILL BE ASSESSED FOR ALL MISSED APPOINTMENTS CANCELLED OR RESCHEDULED WITH LESS THAN 24-HOUR ADVANCED NOTICE, EXCLUDING WEEKENDS AND FEDERAL HOLIDAYS. (Fee is subject to inflation and cost of treatment at the time fee is incurred)

4. I understand that missed appointments will NOT be rescheduled until the $150 fee is paid.

5. I understand Psychiatric Wellness will suspend all future services in the event where 15 days pass by without payment made toward an overdue balance.

6. I understand that if the card on file declines payment after my account is more than 30 days overdue, AND I neglect to contact the office to establish a payment arrangement, a collection-processing fee will be added to the outstanding balance and sent to a collection agency. The collection agency will also add additional processing fees to the total due.
Signature of individual or legal representative required below. *

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PATIENT/PROVIDER EMAIL CONSENT
Psychiatric Wellness APRN-CNP PLLC offers patients, parents or guardians the opportunity to communicate by email. Using email to discuss patient information, however, is different than phone messaging.
E-mail communication has several possible risks that patients, parents or guardians should consider before using. If the patient, parent or guardian is concerned about information being seen by other people, an alternative form(s) of communication such as telephone communication should be used, and the method choice should be chosen below.
Please recognize that we are not a Crisis or Emergent clinic. Any questions that arise are usually answered within 24-48 business hours, Monday through Friday only.
We also ask that you follow the policy and refrain from asking for medication adjustments or for information that can be utilized during a follow-up medication session. Email should strictly be used for difficulties obtaining medications at the pharmacy, appointment requests, or for rescheduling. You may call us at 405-437-2240 and leave us a message.

PATIENT ACKNOWLEDGEMENT AND AGREEMENT
I acknowledge that I have read and fully understand the information the Provider/Practice has provided me regarding the risks of using e-mail. I understand the risks associated with the communication of email between Provider/Practice and I and consent to the conditions outlined. In addition, I agree to the above instructions, as well as any other instructions that the Provider/Practice may impose regarding email communications. By signing below, I am agreeing to use email communication and have been informed of the risk.
Signature of individual or legal representative required below.*

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PAYMENT POLICY CONSENT
Please note that if you are using insurance to pay for part of your visit cost that YOU ARE RESPONSIBLE for verifying your insurance and being aware of any copays, co-insurances, deductibles and costs for any third party services that may be a part of your insurance plan. Examples of third-party services include LABORATORY SERVICES and referrals to OTHER HEALTH CARE PROFESSIONALS. Staff at Psychiatric Wellness will attempt to verify these as well prior to your first visit but please know that it is ultimately your responsibility to verify directly with your insurance company.

Pricing for paperwork to be filled out is $2.50 per minute with a 15-minute minimum if paperwork is filled out by the provider outside of sessions.

Psychiatric Wellness collects copays, coinsurance and deductibles for follow up visits on the day the visit is scheduled versus after the visit has occurred. Please note that these charges will be made to the credit card that you have on file with us.

YOU ARE RESPONSIBLE for letting the office know as soon as you are aware of any UPCOMING INSURANCE CHANGES. If the office is not notified and insurance does not pay, you will be responsible for the full amount of services rendered.

If there are outstanding charges and you have not responded to messages from the office about this with a payment or payment plan within 30 days, the credit card you have on file will be automatically charged for your full outstanding balance.
BY SIGNING BELOW, YOU ARE STATING YOU HAVE READ AND UNDERSTOOD THE PAYMENT INFORMATION DESCRIBED ABOVE*

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APPOINTMENT PREFERENCE
Many of our providers treat our clients virtually via telehealth and some follow a hybrid schedule with both in-person and telehealth availability.
Please be aware, there might be a longer waiting period for an in-person initial evaluation, however you will be offered the earliest date available for your appointment preference.

**Research has shown telehealth treatment to be equal in effectiveness as in-person psychiatric care. Your adherence to treatment and willingness to make changes are the keys to improving your mental health and overall wellbeing**
Please mark your preference below:*

Telehealth OnlyIn-Person OnlyNo Preference (either telehealth or in-person/soonest possible appointment)
Please select yes that you understand in order to have a telehealth appointment you *MUST* have a working blood pressure cuff at home.*

YESNO
Are you interested in seeing a provider for talk-therapy alone? Or Would you like to see a nurse practitioner for integrative psychiatric treatment? Or Both services together? Integrative treatment focuses on treating all body systems in order to optimize mental health outcomes. (Integrative treatment examples: medication management, lab testing, nutritional guidance, exercise advice, recommending vitamins/nutraceuticals, etc.) Explanation of Integrative Psychiatry Services*

Both integrative psychiatry & therapyIntegrative treatment onlyTherapy treatment only (unavailable in Elk City & Insurance: Medicaid, SoonerCare or SoonerSelect)Not sure yet

PRIMARY INSURANCE
As a courtesy, Psychiatric Wellness will verify your insurance coverage prior to scheduling and provide a cost estimation. PLEASE BE AWARE the information provided is NOT a guarantee of payment. Your exact cost will be determined by your plan once the claim is processed.

For this reason, we strongly recommend that you additionally contact your insurer to become familiar with your outpatient mental health coverage.
Your benefits and patient financial responsibility may be unlike your benefits for other healthcare services (such as primary care, urgent care, specialists, etc.).
I understand Psychiatric Wellness provides an estimated cost only. It is my responsibility as a patient/guarantor to understand my insurance coverage.*

I understand the above-stated information regarding insurance coverage
Primary Health Insurance:*
Name of Policy Holder:*
Policy Holder's Relationship to Patient:*
Policy Holder's Date of Birth*

MonthDayYear
Date
Subscriber ID: *Do Not Skip**
Group Number: Enter "NA" if none*

SECONDARY INSURANCE
Secondary Health Insurance:
Name of Policy Holder:
Policy Holder's Relationship to Patient:
Policy Holder's Date of Birth

MonthDayYear
Date
Subscriber ID:
Group Number:

REMINDER PREFERENCE
How would you like to receive reminders about upcoming appointments?*

Text MessageEmailBoth Text & Email

Client Identification & Insurance Card(s)
For identification purposes, prior to scheduling we need the client's Driver License or State ID on file.

For verification of active insurance coverage and to obtain a benefits quote for outpatient psychiatric office, we need the insurance card(s) on file, both FRONT & BACK sides.
DL or State ID upload*

Cancelof
Insurance Card - *Front* *

Cancelof
Insurance Card - *Back* *

Cancelof
The office staff at Psychiatric Wellness typically work remotely and will not be not on-site to collect photos of your cards in-person. If you prefer, you may text photos. The clinic intake coordinator will request them when working on your chart.*

I read the above and understand that Psychiatric Wellness requires photos of my DL/ID & insurance card(s) on file, prior to scheduling with a provider.
Should be Empty:

	Currently experiencing	Experienced in past	Not experiencing
Depressed/sad/"down" mood most of the day, nearly every day
Loss of Interest or pleasure in all, or almost all activities most of the day, nearly every day
Weight loss over the past month
Weight gain over the past month
Decreased appetite nearly every day
Increased appetite nearly every day
Feeling physically agitated (difficulty sitting still, pacing, fidgeting, bouncing leg, etc.)
Recent onset of slowed thinking
Recent onset of slowed speech
Recent onset of slowed or decreased movement
Fatigue or loss of energy nearly every day
Feeling worthless
Frequent feelings of guilt over past failures
Decreased ability to concentrate nearly every day
Decreased ability to think clearly nearly every day
Difficulty making decisions nearly every day
Recurrent thoughts of death (not fear of dying)
Recurrent suicidal ideation without a specific plan
Recurrent suicidal ideation with a specific plan
Worsening mood in winter
Worsening mood in spring
Worsening mood in summer
Worsening mood in fall
Difficulty becoming aroused
Difficulty staying aroused
Difficulty achieving an orgasm

	Currently Experiencing	Experienced in the past	Not Experiencing
Abnormal racing thoughts that change topics quickly
Feeling abnormally hyperactive
Acting unusually impulsive such as making important decisions or acting on urges before thinking it through
Frequently arguing with others
Feelings of intense and abnormal anger/rage
Excessive energy that is unusual for how I usually feel, that has lasted for 2 or more days straight
Periods of time when I am unusually and excessively sexually active. These periods last more than 2 days in a row

	Currently Experiencing	Experienced in the past	Not Experiencing
Constant/Frequent worrying that occurs more days than not for the past 6 months or more
Difficulty controlling worries
Feeling restless (Internal anxiety)
Feeling keyed up/on edge
Easily fatigued
Difficulty concentrating
Mind going blank
Irritable
Muscle Tension
Tired upon waking after having a good amount of sleep
Frequent panic attacks that have had a negative impact on my ability to function
Avoidance of others related to fear of being judged
Racing thoughts related to concerns, worries, and fears
Panic attacks when having to leave home
Frequent fearfulness

	Currently Experiencing	Experienced in the past	Not Experiencing
Intrusive and unwanted thoughts that frequently occur despite attempts to not think of them, which include disturbing content that is out of character for you. These thoughts cause great distress and impair your daily function.
Intrusive and unwanted thoughts that frequently occur despite attempts to not think of them, which include disturbing unlikely events . These thoughts cause great distress and impair your daily function.
Ritualistic behaviors that take at least 1 hr each day to perform and cause extreme distress if I am not able to complete them
Being very particular about how things are done and becoming very upset if they are not done as I think they should be
Becomes upset when things are out of place
Having great distress when there are change in plans or in routines

	Currently Experiencing	Experienced in the past	Not Experiencing
Exposure to actual or threatened death, serious injury, or sexual violence by directly experiencing traumatic event(s); witchnessing the event(s) as it occurred to others; learning a violent or accidental event(s) occurred to a close family member or friend; OR experiencing repeated or extreme exposure to details of traumatic event(s) (First responders, etc.)
Recurrent involuntary, and intrusive distressing memories of the traumatic event(s)
Recurrent nightmares that have a common theme of previous traumatic event(s)
Feeling or acting as if the traumatic event(s) were recurring
Intense or long lasting psychological distress when exposed to reminders, physical or emotional, or traumatic event(s)
Avoidance of, or efforts to avoid, memories, thoughts, or feelings related to traumatic event
Avoidance of, or efforts to avoid, people, places, conversations, activities, objects, or situations that bring up memories, thoughts, or feelings related to traumatic event(s)
Inability to remember important aspects of traumatic event(s)
Persistent negative beliefs about yourself, others, or the world
Persistent thoughts of blaming self or others for the cause or consequences of traumatic event(s)
Persistent/constant anger
Persistent/constant guilt
Persistent/constant shame
Persistent/constant fear
Persistent/constant other negative emotional state
Minimal interest in important activities
Feeling detached and or estranged from others
Constant inability to experience positive emotions
Irritable behavior with angry outbursts (verbal or physical)
Reckless or self-destructive behavior
Feeling constantly on alert
Constantly scanning surroundings for possible threats
Extreme startle response
Previous trauma has effected my ability to be successful in school
Previous trauma has a negative effect on relationships
Previous trauma has had a negative effect on my mood

Adult Intake Questionnaire

CLIENT INFORMATION

Medications Policy

CURRENT SYMPTOMS

IDEATIONS & SELF HARM

MOOD DISORDERS

SUBSTANCE & TOBACCO USE

PSYCHIATRIC HISTORY

MEDICAL HISTORY

FUNCTIONAL MEDICINE QUESTIONNAIRE

SOCIAL HISTORY

Family History

REVIEW OF SYSTEMS

WOMEN ONLY

CLIENT READINESS

PCL-5 with LEC-5 and Criterion A

PHQ-9

GAD-7

Adverse Childhood Experience (ACE) Questionnaire

FUNCTIONAL STATUS QUESTIONNAIRE (FSQ)

INITIAL EVALUATION AGREEMENT

Client Rights Form

Between-Visits Communication Policy Form

Notice of Privacy Practices

EMAIL & TEXT COMMUNICATION CONSENT

TELEHEALTH CONSENT FORM

ETHICAL RESPONSIBILITY OF PROVIDERS

EQUIPMENT NEEDED FOR TELEHEALTH CONSENT

CLINICAL POLICIES

CONSENT FOR TREATMENT

FINANCIAL POLICY

PATIENT/PROVIDER EMAIL CONSENT

PAYMENT POLICY CONSENT

APPOINTMENT PREFERENCE

PRIMARY INSURANCE

SECONDARY INSURANCE

REMINDER PREFERENCE

Client Identification & Insurance Card(s)

	Currently Experiencing	Experienced in the past	Not Experiencing
Finding objects in my possession that I don't remember having
Suddenly appearing in a different room or place and don't remember how I got there
Feeling like my surroundings aren't real or like I am in a dream when I am awake
Feeling like I am not in my body
Not recognizing myself when I look in a mirror

	Currently Experiencing	Experienced in the past	Not Experiencing
Difficulty staying on task due to being distracted by surroundings. This leads to impairment in completing tasks at work, school, and personal responsibilities that may lead to job loss, academic failure, or negative consequences with interpersonal relationships.
Difficulty following directions which has a negative effect on school, work, or interpersonal relationships.
Difficulty keeping focused on tasks to the point it effects my job, my relationships, my academic performance, or my ability to accomplish household responsibilities
Blurting out answers when I am not supposed to
Frequently interrupting other when they are talking

	Currently Experiencing	Experienced in the past	Not Experiencing
Hearing voices or other noises that other people don't seem to hear
Seeing things that other people don't seem to see
Feeling like people or someone is out to get me
Feeling that thoughts are being put into my head
Feeling that someone else is controlling me
Feeling that someone is making me do things
Belief that people can read my thoughts
Feel I am receiving special messages from the TV or news articles

	Currently Experiencing	Experienced in the past	Not Experiencing
Restricting my food intake related to fear of gaining weight
Base my value as a person on my weight and or appearance
Episodes of binging on food that occurs at least 3-4 times per week and include eating a large amount of food in a 2- hour period
Episodes of purging (vomiting) after eating in an attempt to not gain weight
Episodes of other compensatory behaviors in attempt to prevent weight gain, such as use of laxatives, excessive exercise, or any other extreme behaviors

	Currently Experiencing	Experienced in the past	Not Experiencing
Watching pornography excessively to the point it is having a negative effect on my relationships, academic performance, work performance, or ability to tend to responsibilities
Gambling to the point it is having a negative effect on my finances, relationships, academic performance, work performance, or ability to tend to responsibilities

	Yes	No
Did you ever create a plan for suicide?
Did you ever practice or prepare for suicide?
Did you ever have intent to follow through with suicide?
Have you ever attempted suicide?

	Yes	No
Have you ever had serious thoughts or urges to take someone else's life?
If yes, was it a specific person?
Have you ever taken someone else's life?
Do you currently have thoughts and/or urges of taking anyones life?
Have you ever intentionally harmed anyone?

	Yes	No
...felt so good or hyperactive that other people said you were not acting your normal self, or you were so hyper that you got in trouble? you were so hyper that you got in trouble?
...felt so irritable that you shouted at people or started fights or arguments?
...felt much more self-confident than usual?
... only slept for 2-4 hrs and felt like you didn't need anymore?
...were much more talkative than usual or spoke much faster than usual
...thoughts were racing through your mind so quickly you had difficulty keeping up with your thoughts or you couldn't slow your mind down?
...you were easily distracted by things around you that you had trouble concentrating or staying on track
...you had an unusual amount of energy?
...you were more motivated than usual and became more active (began cleaning the whole house, hyperfocused on a goal, fixated on a business idea, immersed in artwork?
...you did things that were unusual or out of character for you?
...you did things that other people thought were excessive, foolish, or risky?
...spending money got you or your family in trouble?
If you marked YES to more than one of the above, have several of these ever happened during the same period of time?
Has a health professional ever told you that you have manic depressive illness or bipolar disorder?

	Yes	No	Don't Know
Were you full a term baby?
A. Preemie?
B. Breast fed?
C. Bottle fed?
As a child did you eat a lot of sugar and/or candy?

	Yes	No
Do you experience symptoms of hypoglycemia such as dizziness, shakiness or brain fog between or following meals?
Do you frequently miss or delay meals?
Do you frequently crave sugar or carbohydrates?
Do you consume excessive sugar or refined carbohydrates?
Are you diabetic or pre-diabetic?
Do you regularly consume alcohol or caffeine?
Do you consume food within 3 hours before bedtime?
Do you consume food within 2 hours before bedtime?

	0- Would never doze	1- Slight chance of dozing	2- Moderate chance of dozing	3- High chance of dozing
Sitting and reading
Watching Television
Sitting inactive in a public place (e.g. a theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped in a few minutes in traffic

	Yes	No
Dermatological: Do you suffer from hives, eczema, or psoriasis?
Immunological: Do you suffer from chronic infections or frequent illness?

	Yes	No
Do you consume at least 5 servings of fruits and vegetables per day?
Do you drink at least eight 8oz glasses of water every day?
Do you regularly consume soft drinks (diet or regular) or fruit juices?
Do you typically snack on chips, cookies, crackers, or granola bars?
Do you eat grain products, white bread, pasta, cereal, chips, and crackers daily?
Do you eat fried foods, fast foods, and packaged food daily?
Does skipping a meal greatly affect your mood?
Do you have an aversion to certain foods?
Are you on a special diet

	More than 5 times	Less than 5 times	No	Unknown
How often have you used antibiotics within the past two years?
How often have you taken antibiotics during infancy/childhood?
How often have you taken antibiotics during teen/adolescence?
How often have you taken antibiotics as an adult?

	Yes	No
Do you frequently feel worried, anxious, or on edge?
Do you consider your job a stressor in your daily life?
Do you consider your relationships a stressor in your daily life?
Do you consider finances a stressor in your daily life
Are you a caregiver for a parent?
Are you a caregiver for a disabled child?
Do you consider school a stressor in your daily life?
Over the past month, do you feel overly stressed?
Do you feel less able to handle stress or experience more stress now than in the past?
Do you experience mental fogginess or have trouble concentrating?
In the last six months, have you unintentionally lost or gained 10 or more pounds?

	Yes	No
Do you participate in group activities at least 3 times per week?
Are you spiritually active at least 4 times per month (e.g. meditate, participate in church activities, prayer, and or other spiritual practices)?
Do you eat some of your meals with family or friends every day?
Do you have one or more pets?
Do you practice stress management techniques such as deep breathing?
Do you feel isolated from friends and family?
Do you feel lonely?
Are you free of physical threats (e.g. personal relationship, workplace, family)?
Are you free of emotional toxins (e.g. personal relationship, workplace, family)?

	Yes	No
Are you experiencing problems falling asleep?
Are you experiencing difficulty staying asleep?
Do you wake up more than twice a night?
Are you sleeping less than 7-9 hours each night?
Do you sleep 7-8 hours a night without help of medication?
Do you awaken not feeling well-rested in the morning?
Do you work 2nd or 3rd shift?
Do you use electronic devices within two hours before bed?
Do you eat within two hours of bedtime?
Do you frequently feel drowsy throughout the day?
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
Has anyone ever observed you stop breathing during your sleep?
Do you have or are you being treated for high blood pressure?
Do you depend on caffeine to get you through the day?
Do you use a blue light filter or glasses at night when on electronics or watching TV?
If you wake up throughout the night, does it take you more than 15 minutes to fall back asleep?

	Yes	No
Do you experience frequent heartburn, burping, gas, or bloating during or immediately after meals?
Have you ever been diagnosed with anemia or any other nutrient deficiency?

	Yes	No
Do you suffer from multiple food sensitivities? (Gluten, dairy, soy, etc)
Do you experience skin issues such as acne, rosacea, or eczema?
Do you have seasonal allergies?

	Yes	No
Do you suffer from multiple food sensitivities? (Gluten, dairy, soy, etc)
Do you eat organically grown and in season foods?
Do you practice intermittent fasting?

	Yes	No
Do you get outside most days of the week for at least 10 minutes?
Do you exercise regularly?
Do you exercise more than 5 times per week?
Do you exercise less than 3 times per week?
Do you participate in physically active hobbies such as gardening or dancing?
Do you perform easy stretching/balancing exercises?

	Yes	No
Do you tend to catch cold easily or recover slowly?
Do you have unexplained rashes, redness, or itching?
Do you get sick often?

	Greater than 5 times	Less than 5 times	Unknown
How often have you taken oral steroids in infancy?
How often have you taken oral steroids in teen/adolescence?
How often have you taken oral steroids in adulthood?

	Yes	No	Uknown
Do you have regular exposure to exhaust fumes, tobacco smoke, pesticides, commercial chemicals, paint, etc?
Have you lived in a house or worked in an office environment with a history of water damage or known mold?
Are you sensitive to smells or fragrances?
Do you drink from plastic bottles/cups and or eat food from plastic plates or containers?
Do you use organic cleaners such as soap, detergent, and shampoo?
Do you currently have mercury fillings?
If you have had mercury fillings removed, did you have all your mercury fillings removed at the same time?
Have you been exposed to lead or other heavy metals (e.g. tin, aluminum, magnesium)?

	Yes	No
Do you currently own your home?
Are you currently renting your home?
Are you temporarily living with someone?
Do you have a yard?
Are you currently in an abusive relationship?
Do you feel safe in your home?

	Yes	No
Did you feel safe growing up?
Have you been involved in abusive relationships in your life?
Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?
Do you currently feel safe in your home?
Do you feel safe, respected and valued in your current relationship?
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?

	Psychiatric Illnesses (Ex. depression, bipolar disorder, anxiety disorders, substance abuse, suicide attempts etc.)	Physical Illnesses (Ex. cancer, diabetes, heart disease, rheumatism or autoimmune disorders, alcoholism, Alzheimer's, etc.)	Deceased	Unknown/Not Applicable
Mother
Father
Brother(s)
Sister(s)
Aunt(s)
Uncle(s)
Maternal Grandparent
Paternal Grandparent

	Mild	Moderate	Severe
Cold hands and/feet
Cold intolerance
Skin flushing
Heat intolerance
None

	Mild	Moderate	Severe
Recent changes in handwriting
Seizures
Fainting episodes
Tingling in arms
Tingling in legs
Difficulty walking
Difficulty with coordination
Difficulty with balance
Difficulty speaking
Jerky movements of arms
Jerky movements of hands
Jerky movements of legs
Abnormal numbness in half of your body
Hand numbess
Finger numbness
Arm numbness
Leg numbness
Feet numbness
Toes numbness
Headaches
Migraines
Weakness in one body part
Weakness in one side of body
Abnormal changes in walking
Difficulty controlling muscle movements
None

	Mild	Moderate	Severe
Ear pain
Ear ringing/buzzing
Hearing loss
Hearing problems
Sensitivity to loud noises
None

	Mild	Moderate	Severe
Canker sores
Dental infections
Crowns
Fillings
Root canal
Tooth extraction
Bleeding gums
Dentures
Dry Mouth
None

	Mild	Moderate	Severe
Binge eating
Bulimia
Can't gain weight
Can't lose weight
Carbohydrate cravings
Carbohydrate intolerance
Poor appetite
Salt cravings
None

	Mild	Moderate	Severe
Back muscle spasms
Calf cramps
Chest tightness
Foot cramps
Joint deformity
Joint pain
Joint redness
Joint stiffness
Muscle pain
Muscle spasms
Muscle stiffness
Muscle twitches: Eyes
Muscle twitches: Arms or legs
Muscle weakness
Tendonitis
Tension headache
TMJ issues
None

	Mild	Moderate	Severe
Bad breath
Dry cough
Productive cough
Hay fever: Spring
Hay fever: Summer
Hay fever: Fall
Hay fever: at changes of season
Nasal stuffiness
Nose bleeds
Post nasal drip
Sinus fullness
Snoring
Sore throat
Wheezing
Winter stuffiness
None