PA New Patient Initial Request Form

Psych Atlanta New Patient Initial Request Form

If this is a medical emergency or you feel you are in danger, please call 911.
Full Government Name:*

First NameLast Name
INITIAL OUTREACH:
SECOND OUTREACH:
FINAL OUTREACH:
Internal Note:
Date of Birth:*

MonthDayYear
Date
Preferred Name:

First NameLast Name
Preferred Pronouns:
Preferred Location:*
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Email:*
Type of Appointment:*
For treatment-resistant depression (TRD):
Primary Reason for Appointment:*
All current medications including Psychiatric medications, non Psychiatric medications and over the counter medications:*
How did you hear about us?*
If you've selected "Other" - Please specify:
Do you have any family members established with Psych Atlanta*

YesNo
Recent Psychiatric Hospitalization?*

YesNo
If you selected "Yes" - Please specify when and where:
Have you ever been seen by Psych Atlanta?*

YesNo
If you selected "Yes" - Please specify:
Have you ever been seen by Georgia Psychiatry and Sleep?*

YesNo
If you selected "Yes" - Please specify:
History of Substance Abuse?*

YesNo
If you selected "Yes" - Please specify:
Have you ever been diagnosed with a personality disorder?*

YesNo
If you selected "Yes" - Please specify:
Have you ever been diagnosed with an eating disorder*

YesNo
If you selected "Yes" - Please specify:
Any allergies:*

YesNo
If you selected "Yes" - Please specify:
Will you authorize a Release of Information by your provider to obtain previous medical records and medical history related to your care?*

YesNo
Method of Payment:*

InsuranceSelf Pay
Insurance Plan:

BCBSUHC/UMRAetnaCignaMedicareTricareOther
Member ID Number:
Interested in Our Research Studies?*

YesNoMaybe, I want more information
By signing/submitting your New Patient Request Form:

I am aware Psych Atlanta DOES NOT provide services for patients that are seeking a one time court ordered appointment, Workers Compensation cases, appointments for FMLA/Disability Forms ONLY, or patients seeking service animal forms ONLY.

I am aware Psych Atlanta providers DO NOT fill out any forms until I have been an established patient for at LEAST 6 months.

Based upon clinical assessment and judgement, your provider will determine the appropriate treatment options and in partnership with you will individualize prescriptions tailored to your needs and goals. There should not be an expectation to continue any prescriptions you are currently taking or start new medications.
Please sign below that you have read and agree to the above statements:*

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Psych Atlanta New Patient Initial Request Form