Short PAQ

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Hi there! Let's get started!Step 1: Demographics Step 2: Insurance Information Step 3: Clinical Information
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Who is completing the questionnaire?* This field is required.To learn more about our policy on minors, click here.
Prospective adult patient
Spouse, friend, or caregiver of adult patient
Parent or guardian of a minor
Referral sent by outside provider
Evolve Team Member
Other
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If completing this form on behalf of another individual who will be the patient, please enter your own information here.* This field is required.Leave blank if you are the patient
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Patient Name* This field is required.
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / 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
Country
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Date of Birth* This field is required.
Date
Month
Day
Year
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Contact Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Thank you for submitting your Demographics. Let's move on to the next step!Step 1: Demographics Step 2: Insurance Information Step 3: Clinical Information
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How will you be billed for your care?* This field is required.See our cash pay fee schedule here.
Private Pay (Cash)Insurance
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Name of Primary Insurance *
Member ID Number *
Group Number *
Policy Holder *
Policy Holder D.O.B. *
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Name of Secondary Insurance
Member ID Number
Group Number
Policy Holder
Policy Holder D.O.B.
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Choose how you would like to provide an image of patient's insurance card and legal ID.* This field is required.
Upload images from camera (preferred)
Email/text copy of cards (longer processing time)
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Legal Photo Identification* This field is required.Drivers License, State ID or Passport for any adult patient over the age of 18. For minors, please upload parent or policyholder's ID.
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Primary Insurance Card* This field is required.Upload a clear picture of the FRONT of the card
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Primary Insurance Card* This field is required.Upload a clear picture of the BACK of the card
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Secondary Insurance CardUpload a clear picture of the FRONT of the card
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Secondary Insurance CardUpload a clear picture of the BACK of the card
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One more step and you're done!Step 1: Demographics Step 2: Insurance Information Step 3: Clinical Information
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How did you discover Evolve Psychiatry?
Recommended by a current patient
Referred by outside provider
Health insurance carrier website
Hospital / facility discharge summary
Google search
Psychology Today
Select all that apply.
Enter the name of referring party (If Applicable)
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What are the reasons for inquiry?* This field is required.
Please Select
Medication management +/- counseling
Treatment for ADHD
Work or school accommodations letter
FMLA/Short Term Disability application
FAA report
VA Disability Nexus letter
Medical clearance letter for duty/surgery/procedure
Treatment for substance dependency
Only seeking referrals for counseling/therapy
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ADHD Treatment Criteria* This field is required.
I have an official ADHD diagnosis by a neuropsychological evaluation.
I have been on stimulants for at least one year within the state of Texas or California.
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.
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Do you wish to be considered for the supplemental ADHD diagnostic evaluation?* This field is required.You can find more information about the ADHD Diagnostic Evaluation here.
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.
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What substance would you like assistance with quitting?* This field is required.
Please Select
Please Select
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)
Select all that apply
List your frequency of usage in the past 2 months
What complications of quitting are you needing assistance with?
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Briefly expand on your reason for consultation.* This field is required.Important Note: Include past diagnoses AND medications.
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Ok
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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)
Medical conditions such as abnormal heart rhythm, seizures, pregnancy, kidney or liver disease, HIV, cancer, etc.
Any history of self-harm, suicidal thoughts and/or actions
Age of 65+ years old
None of the above
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Please explain your situation in more detail.* This field is required.
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Ok
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Higher level of care and/or Self-harm* This field is required.
For any past higher level of care or suicidal thoughts/actions, when was the most recent occurrence?
Please briefly explain the circumstances and resolution of the incident.
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Action Required: Submit Your Insurance Card Images

Since you have manually submitted your insurance information, please send us clear images of your insurance card (front AND back) at your earliest convenience to prevent any delays. You can submit them through one of the following methods:

Email: benefits@evolvepsychiatrymd.com
Text: (469) 833-3630

If you have any questions or need assistance, feel free to reach out to us. Thank you for your prompt attention!
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Please provide a signature verifying that your submission is true to the best of your knowledge.* This field is required.
Clear
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Thank you for completing the Pre-Assessment Questionnaire. Don't forget to click the SUBMIT button!
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Do you have a secondary insurance?
YESNO
Should be Empty: