Varsha_Wellness_Child_Adolescent_Intake_Packet

Varsha Wellness - Child & Adolescent New Patient Intake Packet

Potomac, MD(301) 661-2375 Integrative Psychiatry
Child Name
Date of Birth Age

MonthDayYear
Date
Gender Pronouns
ParentGuardian Name
Address
Phone/Email
Emergency Contact (Name/Relation/Phone)
Section B: Presenting Concerns
Chief Complaint
Current Symptoms (check all that apply):

DepressionAnxietyADHDBehavioral IssuesTrauma/PTSDSleep ProblemsDevelopmental Concerns
Other
Section C: Psychiatric History
Previous Diagnoses Hospitalizations Treatments

Type a question

	Medication	Dose	Dates Taken	Response	Side Effects
1
2
3
4
5
6
7
8
9
10

Section D: Medical History
Medical Conditions
Allergies
Primary Care Provider
Section E: Family Psychiatric & Medical History
Check all that applies:

DepressionAnxietyBipolarSchizophreniaADHDSubstance UseSuicide AttemptsOther
Section F: Development History
Pregnancy Birth Complications
Developmental Milestones (speech,motor,social)
Early Temperament/Behavioral Issues
School Performance/IEP/504 Plan
Section G: Social History
Living Situation
School / Education
Peer/Family/Relationships:
Legal Issues
Hobbies / Strengths
Section H: Substance Use History
Check all that apply:

TobaccoAlcoholCannabis
Other
Frequency Duration
Section I: Integrative Wellness
Nutrition
Exercise
Mindfulness / Meditation / Yoga
Spiritual / Cultural Factors
Section J: Safety & Risk Assessment
Check all that apply:

Suicidal ThoughtsSuicide AttemptsHomocidal ThoughtsAccess to Weapons
Section K: Review of Systems

	Sleep	Appetite	Energy	Mood	Concentration
Service Quality

Section L: Consent & Acknowledgment

I, the undersigned parent/guardian, consent to psychiatric evaluation and treatment at Varsha Wellness.
ParentGuardian Signature

Clear
Date

MonthDayYear
Date
Provider Signature

Clear
Date

MonthDayYear
Date
Varsha Wellness - Psychiatric Medication Consent

(301) 661-2375 Integrative PsychiatryPotomac, MD
Patient Name
Date of Birth

MonthDayYear
Date
Initials
I understand that psychiatric medication(s) have been recommended by my clinician to help treat mental health symptoms and improve daily functioning.
Initials
I have been informed that medication may reduce symptoms, improve daily functioning, and enhance psychotherapy or other treatments.
Initials
I understand that all medications carry risks and side effects, including but not limited to appetite/sleep changes, headaches, dizziness, mood changes, and rare but serious risks (e.g., allergic reactions, cardiovascular effects, suicidality in youth I will report concerning side effects immediately.
Initials
I have been informed of alternatives including psychotherapy, lifestyle interventions (nutrition, exercise, sleep), or no treatment (with associated risks
Initials
I understand that regular follow-ups are required. Some medications may require labs or EKGs. I agree not to stop medication suddenly without consulting my provider.
Initials
I understand my treatment information is confidential under HIPAA and state law. Varsha Wellness upholds stricter confidentiality practices whenever possible.
Initials
I have the right to ask questions, refuse or withdraw consent, request changes, and review consent periodically.

I have read and understood the information above. My questions have been answered. By signing below, I consent to the use of psychiatric medication(s) as part of my treatment plan at Varsha Wellness.

Patient / Guardian Signature: Provider Signature:
Patient Guardian Signature

Clear
Date

MonthDayYear
Date
Provider Signature

Clear
Date

MonthDayYear
Date
Varsha Wellness - Out-of-Network Provider Consent

(301) 661-2375 Integrative PsychiatryPotomac, MD
Patient Name
Date of Birth

MonthDayYear
Date
1. Out-of-Network Provider Status
Initials
I acknowledge that Varsha Wellness is an out-of-network provider and does not participate with any insurance panels. Services provided are not directly billed to insurance by Varsha Wellness.
2. Financial Responsibility
Initials
I understand that payment is due at the time of service (cash, credit/debit card, or HSA/FSA accepted - I acknowledge that I am fully responsible for all charges incurred for my care. - I understand that I may submit receipts to my insurance company for possible reimbursement, but Varsha Wellness does not guarantee reimbursement. - I agree that Varsha Wellness will not be held liable for insurance company denials, delays, or non-payment of claims.
3. Confidentiality
Initials
- I understand that Varsha Wellness upholds strict confidentiality practices that go beyond HIPAA requirements. - My information will not be shared with insurance companies unless I request that a superbill or receipt be provided for reimbursement purposes. - I understand that my information is protected under federal and state law and will only be disclosed with my written consent, except in cases of safety concerns (risk of harm to self/others) or when required by law.

4. Acknowledgement

I have read and understood this Out-of-Network Provider Consent Form. I agree to the terms and conditions described above.

Patient Signature: Provider Signature:
Patient Signature

Clear
Date

MonthDayYear
Date
Provider Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

1. Out-of-Network Provider Status

2. Financial Responsibility

3. Confidentiality