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 with out 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.

We do not treat minors. Our clinic serves adult patients only. If you are the legal guardian of an adult and completing the packet on their behalf, please include proof of guardianship.

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 online at www.ppaya.com/psgp. 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*

Clear
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.
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
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*

Phone Number*
Please enter a valid phone number.
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?*

YesNo
Have you ever participated in self-help groups? (NA, AA, SAA, etc,)*

YesNo

Current Weight:*
Current Height:*
Have you ever had a traumatic brain injury?*

YesNO
Have you ever had seizures?*

YesNO
List all medication allergies:*
List all current prescription medications and how often you take them:
List all current medical conditions:*

ONE TIME AUTHORIZATION AGREEMENT (MEDICARE INSURANCE PATIENTS ONLY)
I (print name)blanksrequest that payment of the authorized Medicare or other insurance benefits be made on my behalf for any services furnished by PSGP Psychiatric Clinicians. I authorize any holder of medical psychiatric information about me to be released to the Health Care Financing Administration and its agents for any information needed to determine these benefits for related services. I understand my signature requests payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance indicated in item 9 of the HCFA 1500 form or elsewhere on other approval claim forms, my signature authorized releasing the information to the insurer or agency shown. Payment is to go to the provider for services rendered.
Patient Signature

Clear
Date

MonthDayYear
Date
Consent of Legal Guardian or Personal Representative is necessary if patient is unable to sign or is a minor. Proof of such will be required.
Guardian/Parent/Personal Representative Signature:

Clear
Relationship to the patient:
Date

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

A Notice of Policies and Practices to protect the privacy of your patients health information has been given to me and I understand the provisions. I understand that the terms of the Notice may change and that I may obtain a revised copy by contacting the Privacy Office listed in the notice.

I am signing that I understand and have received the HIPPA policy form:
Patient Signature*

Clear
Date*

MonthDayYear
Date
Consent of Legal Guardian or Personal Representative is necessary if patient is unable to sign or is a minor. Proof of such will be required.
Guardian/Parent/Personal Representative Signature:

Clear
Relationship to the patient:
Date

MonthDayYear
Date

CONSENT TO RELEASE INFORMATION (TO INSURANCE COMPANY)

Your records which are held in custody by PSGP Psychiatric Clinicians, are privileged and confidential. A general medical authorization to release psychiatric and/or psychological information is invalid according to Federal Regulation, 42, CFR, Part 2. Your records will not be released without this waive, or one that complies with office policy, except under the following circumstances: In the event of a valid court order or an emergency.
Patient name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Social security number*
I authorize PSGP Psychiatric Clinicians to release to my INSURANCE COMPANY
NAME OF INSURANCE COMPANY:blanks*(PLEASE WRITE “N/A” IF YOU DO NOT HAVE INSURANCE)
The following information will be released if necessary:
**DIAGNOSIS, PROGNOSIS, PROGRESS NOTES, DATES OF SERVICE** *to include any substance abuse information and psychiatric records*

Purpose or need for this information: PAYMENT ON CLAIMS, VERIFY BENEFITS

This consent will expire upon satisfaction of the need for disclosure, unless otherwise specified. I may revoke this authorization at any time provided I notify PSGP Psychiatric Clinicians in writing to that effect. However, such revocation will have no effect on any action previously taken. I understand that once the specified information herein has been disclosed to the recipient, that entity and or previously taken. I understand that one the specified information herein has been disclosed to the recipient, that entity and or recipient may re-disclose the information received and said information may no longer be protected by the Federal Privacy Laws.

Will expire upon satisfaction of the need for disclosure, not to exceed 90 days after termination of treatment.
Patient Signature *

Clear
Date*

MonthDayYear
Date
Patient/Guardian Signature

Clear
Date

MonthDayYear
Date
CONSENT TO RELEASE INFORMATION (TO PRIMARY CARE PHYSICIAN)

Your records which are held in custody by PSGP Psychiatric Clinicians, are privileged and confidential. A general medical authorization to release psychiatric and/or psychological information is invalid according to Federal Regulation, 42, CFR, Part 2. Your records will not be released without this waive, or one that complies with office policy, except under the following circumstances: In the event of a valid court order or an emergency.
Patient name

First NameLast Name
Date of birth

MonthDayYear
Date
Social Security Number
I authorize PSGP Psychiatric Clinicians to release to my PRIMARY CARE PHYSICIAN
NAME OF PRIMARY CARE PHYSICIAN/ADDRESS:
blanks*
(PLEASE WRITE “N/A” IF YOU DO NOT HAVE A PCP PHYSICIAN OR YOU WISH NOT TO RELEASE INFORMATION TO ONE AT THIS TIME)

The following information will be released if necessary:
**LETTER TO PRIMARY CARE PHYSICIAN TO INCLUDE; DIAGNOSIS, PROGNOSIS, PROGRESS

NOTES, DATES OF SERVICE, MEDICATIONS, AND RECOMMENDED TREATMENT.** *to include any substance abuse information and psychiatric records*

Purpose or need for this information TO NOTIFY PRIMARY CARE PHYSICIAN OF PATIENT STATUS

This consent will expire upon satisfaction of the need for disclosure, unless otherwise specified. I may revoke this authorization at any time provided I notify PSGP Psychiatric Clinicians in writing to that effect. However, such revocation will have no effect on any action previously taken. I understand that once the specified information herein has been disclosed to the recipient, that entity and or previously taken. I understand that one the specified information herein has been disclosed to the recipient, that entity and or recipient may re-disclose the information received and said information may no longer be protected by the Federal Privacy Laws.

Will expire upon satisfaction of the need for disclosure, not to exceed 90 days after termination of treatment.
Patient Signature

Clear
Date

MonthDayYear
Date
Patient/Guardian Signature

Clear
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