New Patient Appointment Request for Child/Adolescent

Name of parent filling out this form*
Who does the patient live with? *
Who has legal custody? Please describe the arrangement.*
If the patient's parents are separated or divorced and share custody, we require permission from both parents in order to schedule an appointment
If applicable, can we send a consent form to the other parent*

YesNoNot applicable
Name of Other Parent/Guardian
Phone Number of Other Parent/Guardian
Email Address of Other Parent/Guardian

Thank you so much for your interest in our practice. Currently, none of our providers specialize in this particular area. By continuing with your submission, you understand that we may refer you to another provider who can best meet your needs.

What type of treatment would you like your child to receive? Check all that apply*

Psychiatry- MedicationTherapy- Talking and Problem-Solving TechniquesTreatment Resistant Depression treatment- TMS, Spravato, KetaminePsychoeducational Testing

Thank you so much for your interest in our practice. Currently, none of our providers offer psychological testing. By continuing with your submission, you understand that we may refer you to another provider who can best meet your needs.

Which are the best days for a first appointment?*

MondayTuesdayWednesdayThursdayFriday
Which are the best times for a first appointment?*

Morning (9am-12pm)Early Afternoon (12pm-3pm)Late Afternoon (3pm-5pm)

Please provide a list of all current and previous medications taken for mental health. Include the medication name and dosage.*
Primary Insurance Company*
Member ID*
Please upload your primary insurance card (FRONT)

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Please upload your primary insurance card (BACK)

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Secondary Insurance Company
Member ID
Please upload your secondary insurance card (FRONT)

Cancelof
Please upload your secondary insurance card (BACK)

Cancelof
During the past two (2) weeks, how much or how often has your child been bothered by the following problems?
Complained of stomachaches, headaches, or other aches or pains?*
Said they were worried about their health or getting sick?*
Had problems sleeping: falling asleep, staying asleep, sleeping too much or too little?*
Had trouble paying attention when they were in class, doing their homework, reading a book, or playing a game? *
Had less fun doing things than they used to?*
Seemed sad or depressed for several hours? *
Seemed more irritated or easily annoyed than usual?*
Seemed angry or lost their temper? *
Started more projects than usual or did more risky things than usual? *
Slept less than usual, but still had lots of energy? *

Said they felt anxious, nervous, or scared?*
Not been able to stop worrying? *
Said they couldn't do things they wanted to do or should have done because it made them feel nervous? *
Said that they heard voices speaking about them or telling them what to do when there was no one there?*
Said that they saw something or someone that no one else could see? *
Said that they had thoughts that kept coming into their mind that they would do something bad or something bad would happen to them or someone else? *
Said they felt the need to check on things over and over again, like if a door is locked or a stove is turned off?*
Worried about a lot of things they touched having germs, being dirty, or being poisoned? *
Said they had to do things in a certain way, like counting or saying special things out loud, in order to stop something bad from happening? *

Has your child EVER...
Had an alcoholic beverage?*
Smoked a cigarette, a cigar, or marijuana in any form? Used nicotine products such as vapes or e-cigarettes?*
Taken medication without a doctor's prescription or used drugs?*
Talked about wanting to kill themselves?*
Been physically aggressive toward others*
Failed multiple classes or grades*
Been suspended or expelled from school?*
Had a severe developmental disability that leads to severe difficulty communicating with others or doing basic tasks?*
Have they ever tried to kill themselves?*
Have they ever been diagnosed with an eating disorder? *
Been hospitalized for a mental health reason*
If yes, please list the date and reason for the hospitalization.
Attended a Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP)?*

COVID-19 & Infectious/Communicable Disease Liability Waiver

Please read and acknowledge the following:

COVID-19 Safety Measures
Our office is no longer implementing additional COVID-19-specific precautions (such as universal masking, enhanced distancing, or routine screening) beyond standard infection control protocols required by healthcare regulations.
Personal Responsibility
By entering our facility, you acknowledge that:

You are voluntarily seeking care and services at our office.
You understand that COVID-19 remains a communicable illness with potential health risks.
You are responsible for your own personal precautions (e.g., masking, distancing, sanitizing) if you so choose.

Health Disclosure
You agree to inform our staff prior to your visit if you:

Have tested positive for COVID-19 within the past 10 days.
Have been exposed to someone known or suspected to have COVID-19 within the past 10 days.
Are experiencing any symptoms consistent with COVID-19 (including but not limited to fever, cough, fatigue, or loss of taste or smell).

Assumption of Risk
Despite our efforts to maintain a clean and safe environment, you acknowledge that:

There is an inherent risk of exposure to COVID-19 in any public or healthcare setting.
By attending your appointment, you voluntarily assume all risks related to potential exposure.

HIPAA Policy

Our office is committed to maintaining compliance with HIPAA regulations to ensure
the privacy and security of patient information. Once an appointment is scheduled, the patient will receive our full HIPAA policy to review, outlining our practices and
procedures for safeguarding their confidential health information.
Establishing Care with Our Practice

A psychiatric evaluation by Dr. Robbins or one of our clinicians does not ensure you
will become a patient of the practice. It may be his/her opinion that you need more
intensive services from what can be provided in the office. At that time, Dr. Robbins
will provide you with referrals of programs you can receive such services from. If after the completion of your evaluation with your clinician, he or she feels you can be treated in the office, certain recommendations will follow. You will be required to follow the recommendations provided by the clinician during the course of treatment. If for any reason, the clinician feels you are not complying with the recommendations, you may be discharged from the office for non compliance. Other reasons you may be discharged from the office include: repeatedly missing appointments, not being responsive to phone calls from office, failure to make payments in a timely manner or any misuse of medications being prescribed to you by your clinician. If you are discharged from the office and are being prescribed medications, your clinician will make sure to provide you with enough refills for up to 1-2 months to give you ample time to connect with a new provider.
Working with Our Clinicians

I understand that my initial appointment may be scheduled with either Dr. Robbins, a licensed psychiatrist, or with a qualified psychiatric nurse practitioner, depending on provider availability and scheduling needs. While you can request a first appointment with Dr. Robbins, earlier appointments may be available with one of our experienced psychiatric nurse practitioners. All psychiatric nurse practitioners in this practice are fully licensed, highly trained, and work in close collaboration with Dr. Robbins. If I begin care with Dr. Robbins, I understand that follow-up appointments may be scheduled with a psychiatric nurse practitioner if recommended as appropriate for my treatment plan. Regardless of which provider I see, my care will remain under the clinical oversight of Dr. Robbins to ensure quality, consistency, and continuity. By signing below, I consent to receive care from the qualified providers within this practice as determined by clinical judgment and availability.
I affirm that all information provided above is accurate and complete to the best of my knowledge. I understand that submission of this information does not guarantee an appointment with this practice. I acknowledge that the New Patient Coordinator may review my information and, based on clinical and logistical considerations, may recommend an alternative provider or practice better suited to my needs.
Signature*
Patient Name*
Parent/Guardian's Name*
if printed, sign here
Date*
Should be Empty:

Appointment Request Form

If the patient's parents are separated or divorced and share custody, we require permission from both parents in order to schedule an appointment

Thank you so much for your interest in our practice. Currently, none of our providers specialize in this particular area. By continuing with your submission, you understand that we may refer you to another provider who can best meet your needs.

Thank you so much for your interest in our practice. Currently, none of our providers offer psychological testing. By continuing with your submission, you understand that we may refer you to another provider who can best meet your needs.

During the past two (2) weeks, how much or how often has your child been bothered by the following problems?

Has your child EVER...

COVID-19 & Infectious/Communicable Disease Liability Waiver

Please read and acknowledge the following:

HIPAA Policy

Establishing Care with Our Practice

Working with Our Clinicians

Appointment Request Form

If the patient's parents are separated or divorced and share custody, we require permission from both parents in order to schedule an appointment

Thank you so much for your interest in our practice. Currently, none of our providers specialize in this particular area. By continuing with your submission, you understand that we may refer you to another provider who can best meet your needs.

Thank you so much for your interest in our practice. Currently, none of our providers offer psychological testing. By continuing with your submission, you understand that we may refer you to another provider who can best meet your needs.

During the past two (2) weeks, how much or how often has your child been bothered by the following problems?

Has your child EVER...

COVID-19 & Infectious/Communicable Disease Liability Waiver Please read and acknowledge the following:

HIPAA Policy

Establishing Care with Our Practice

Working with Our Clinicians

COVID-19 & Infectious/Communicable Disease Liability Waiver

Please read and acknowledge the following: