Psychiatric Services of Grosse Pointe Intake Form

Dear Patient,

Thank you for your interest in scheduling an evaluation at PSGP - Psychiatric Clinicians. Please review the following information carefully before submitting your intake packet:

Initial Appointments: Evaluations are conducted in person at our Roseville office. We do not offer telehealth services. Patients must reside in Michigan to receive care. We do not accept Medicaid without an authorization.

Follow-Up Care: Patients may be evaluated by a psychiatrist (MD or DO), but follow-up visits for medication management may be scheduled with one of our physician assistants (PA-C). Yearly reviews may be completed by an MD or DO.

Therapy Services: Our MDs and PAs do not provide psychotherapy. However, they can refer you to a therapist within our office or in the local community.

Patient Age Requirements: Our clinic serves patients ages 16 and older. If you are the parent or legal guardian of a minor (ages 16–17) and are completing the packet on their behalf, please include appropriate consent and documentation as required.

Insurance and Fees: Please provide your insurance information so we can verify coverage. If not covered, the initial evaluation is $330. Follow-up visits start at $150. Payments can be made by phone at 586-252-2616 or through our secure online payment portal: https://paymnt.io/pbd8y3. Guest payments can be made without a bill.

E-Prescriptions Only: All prescriptions are sent electronically. Please have your pharmacy information available during your appointment. We do not issue paper prescriptions.

Submitting Your Packet: Intake forms must be completed by the individual seeking treatment. Only the patient will be contacted for scheduling. All sections must be filled out. If a section does not apply, please mark it as “N/A.” Incomplete packets will not be reviewed. If you have had your packet for more than 30 days, contact the office before submitting to ensure no updates are needed.

If you have any questions, feel free to call us at 586-252-2616 or email frontdesk@psgp.info.

Thank you,

Please initial next to each item that you have read, understand, and agree to the following consent, information and policy forms. Each of these documents are available on 24/7 our website and can also be provided to you by the staff upon request.
FMLA/INSURANCE/NEW PATIENT RESCHEDULING FORM
NO SHOW & CANCELATION POLICY
CONTROLLED SUBSTANCE POLICY
ACCOUNT BALANCE POLICY
Patient Name

First NameLast Name
Signature
Date

MonthDayYear
Date

Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Age
Social Security Number
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Insurance
Contract/Member ID
Group #
Subscribers Name
Subscribers Date of Birth

MonthDayYear
Date
Secondary Insurance
Contract/Member ID
Group #
Subscribers Name
Subscribers Date of Birth

MonthDayYear
Date

Primary Care Physician (write N/A if applicable)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Were you referred to PSGP?
Were you referred to a specific provider at PSGP? If yes, specify who.
Is your primary care and referral source the same? If no, complete info below.
Referral Source
Referral Name

Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please describe any (past/present) alcohol use:
Please describe any (past/present) recreational drug use:
Please describe any (past/present) tobacco use:
Have you ever received treatment for alcohol/drug use?
Have you ever participated in self-help groups? (NA, AA, SAA, etc,)

Current Weight:
Current Height:
Have you ever had a traumatic brain injury?
Have you ever had seizures?
List all medication allergies:
List all current prescription medications and how often you take them:
List all current medical conditions:

Assignment of Benefits and Authorization (Medicare Patients Only)

I authorize payment of Medicare and any other applicable insurance benefits directly to PSGP - Psychiatric Clinicians for services provided to me.

I authorize PSGP - Psychiatric Clinicians to release any medical or psychiatric information necessary to process my claims, coordinate benefits, and obtain payment for services rendered. This may include sharing information with Medicare, other insurance carriers, and their authorized agents.

I understand that I am financially responsible for any charges not covered by my insurance.
Patient Signature
Date

MonthDayYear
Date
Guardian or Personal Representative Signature (Only if applicable)
Consent of a legal guardian or personal representative is required if the patient is a minor or unable to sign. Proof of such may be required.
Guardian/Parent/Personal Representative Signature:
Relationship to the patient:
Date

MonthDayYear
Date
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES NOTICE (HIPAA POLICY- Health Insurance Portability & Accountability Act)

I acknowledge that I have been provided access to PSGP – Psychiatric Clinicians’ Notice of Privacy Practices, which explains how my medical information may be used and disclosed and how I can access this information.

I understand that I may request a copy of this notice at any time.

By signing below, I acknowledge that I have been provided access to PSGP – Psychiatric Clinicians’ Notice of Privacy Practices.
Patient Signature
Date

MonthDayYear
Date
Guardian or Personal Representative Signature (Only if applicable)
Required if the patient is unable to sign.
Guardian or Personal Representative Signature Signature:
Relationship to the patient:
Date

MonthDayYear
Date

CONSENT FOR TREATMENT

By signing this form, I am requesting and giving my consent to PSGP - Psychiatric Clinicians and its physicians, physician assistants, psychologists, therapists, clinical staff, administrative staff, and other authorized staff to provide me with outpatient medical and mental health treatment, evaluation, testing, medication management, psychotherapy when applicable, coordination of care, and related services.

I understand that outpatient psychiatric and mental health treatment may involve discussing difficult symptoms, experiences, stressors, or personal history. I understand that treatment may cause temporary emotional discomfort, including anxiety, sadness, distress, or other symptoms.

I understand that certain medications may be prescribed in connection with treatment and that such medications may have known and unknown risks, benefits, side effects, and alternatives. I understand that some medications may be prescribed for uses that differ from their specific FDA approved indication when clinically appropriate.

I understand that no guarantee or promise, oral or written, has been given by anyone regarding the result of treatment, or regarding the risks, consequences, or complications that may be involved in treatment.

I understand that if I have questions about my medical or mental health care, testing, medications, or treatment plan, I should ask my provider. I understand that it is my responsibility to tell my provider about all medications, drugs, supplements, substances, allergies, and medical conditions that may affect my care.

I understand that PSGP - Psychiatric Clinicians may use and disclose my health information as permitted by law for treatment, payment, and health care operations. This may include communication with other health care providers involved in my care when clinically appropriate. I understand that certain disclosures may require a separate written authorization or release of information form.

I understand that communication with my primary care provider or referring provider may be appropriate for coordination of care. I agree to disclose information regarding my physical health, and I understand that records or reports from other health care providers may be requested when clinically appropriate and as permitted by law.

FEES AGREEMENT

I understand that it is my responsibility to obtain information about my insurance coverage from my employer or insurance carrier. I understand that PSGP - Psychiatric Clinicians staff may assist me in obtaining benefit information as a courtesy, but benefit information provided by insurance is not a guarantee of payment.

I understand that PSGP - Psychiatric Clinicians will bill for charges related to services provided to me. I agree to pay PSGP - Psychiatric Clinicians for services rendered after I am billed.

I understand that PSGP - Psychiatric Clinicians is not responsible if an insurer, government payer, or third party payer does not pay for services. I agree that I am responsible for any charges not paid by insurance or another third party payer, including copays, deductibles, coinsurance, noncovered services, and denied claims, unless prohibited by law or by an agreement between PSGP - Psychiatric Clinicians and my health insurer.

If I file a claim for hospital, surgical, physician, disability, no fault, liability, or other health benefit insurance related to services rendered by PSGP - Psychiatric Clinicians, I assign to PSGP - Psychiatric Clinicians any benefits payable for those services. I agree to sign any necessary authorizations or consents requested by PSGP - Psychiatric Clinicians to allow my insurance company or other payer to pay PSGP - Psychiatric Clinicians directly.

I UNDERSTAND THAT I MAY BE CHARGED FOR MISSED APPOINTMENTS THAT HAVE NOT BEEN CANCELED AT LEAST 24 HOURS BEFORE THE SCHEDULED APPOINTMENT TIME.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT FOR TREATMENT AND FEES AGREEMENT.
Patient Signature
Date

MonthDayYear
Date
Patient/Guardian Signature
Date

MonthDayYear
Date
Upload Front and Back of Picture ID and ALL Health Insurance Cards (Passports not accepted)

Cancelof
Should be Empty:

Rows	Not at all	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

Rows	Not at all	Several Days	More than half the days	Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Rows	Yes	No
…you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
…you were so irritable that you shouted at people or started fights or arguments?
…you felt much more self-confident than usual?
…you got much less sleep than usual and found you didn’t really miss it?
…you were much more talkative or spoke faster than usual?
…thoughts raced through your head or you couldn’t slow your mind down?
…you were so easily distracted by things around you that you had trouble concentrating or staying on track?
…you had much more energy than usual?
…you were much more active or did many more things than usual?
…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
…you were much more interested in sex than usual?
…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
…spending money got you or your family in trouble?

Rows	Never	Rarely	Sometimes	Often	Very Often
1. How often do you have trouble wrapping up the final details of a project, once thechallenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task thatrequires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay gettingstarted?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for along time?
6. How often do you feel overly active and compelled to do things, like you were driven by amotor?
7. How often do you make careless mistakes when you have to work on a boring or difficultproject?
8. How often do you have difficulty keeping your attention when you are doing boring orrepetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when theyare speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or in other situations in which you areexpected to stay seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of thepeople you are talking to, before they can finish it themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

Rows	Not at all or very slightly	Mildly	Moderately	Quite a bit	Very much
1. concentration problems, easily distracted
2. anxious, worrying
3. nervous, fidgety
4. inattentive, daydreaming
5. hot- or short-tempered, low boiling point
6. temper outbursts, tantrums
7. trouble with stick-to-it-tiveness, not following through, failing to finish things started
8. stubborn, strong-willed
10. disobedient with parents, rebellious, sassy
11. low opinion of myself
12. irritable
13. moody, ups and downs
14. angry
15. acting without thinking, impulsive
16. tendency to be immature
17. guilty feelings, regretful
18. losing control of myself
19. tendency to be or act irrational
20. unpopular with other children, didn't keep friends for long, didn't get along with other children
21. trouble seeing things from someone else's point of view
22. trouble with authorities, trouble with school, visits to principal's office
23. overall a poor student, slow learner
24. trouble with mathematics or numbers
25. not achieving up to potential

PHQ-9 & GAD-7

Mood Disorder Questionnaire (MDQ)

WURS-25