New Patient Intake Form

New Patient Intake Form

Please complete this form to help us provide you with the best care. Your information is kept confidential.
Dear Patient,

We are so glad you have chosen to begin your mental wellness journey with us. At Catalust Integration for Health we are commited to providing compassionate, evidence-based care tailored to your unique needs. We treat ages 10 and up. Whether you are seeking support for emotional well-being, medication management, or personal growth, our goal is to create a safe and supportive space for healing and transformation. We do reserve the right to perform drug screening at random.

Initial consultation $200.00, follow-up visits $150.00 and drug screening is $40.00. For all patients there will be a $50.00 fee if you do not show up for your visit or do not cancel your visit 24 hours before your scheduled appointment time. If you are 10 minutes late for your visit, even if you call on the way in, it will be considered a no show, and you will need to reschedule your visit and will be charged $50.00 no show fee. If you are late and the schedule allows, we will try to fit you in, however this is not a guarantee as we have other patients scheduled and may not be able to accommodate you. Even if we are able to fit you in you will be charged a late fee of $50.00. This includes in-person and telehealth appointments.

We look forward to working together to help you elevate and emerge into the best version of yourself. If you have any questions or need support, don't hesitate to reach out. You can call us at 916-850-2299

Warmly,

Catalyst Integration for Health
Recipient's Rights Notification

Your rights as a patient
1. Complaints. We will investigate your complaints.
2. Suggestions. You are invited to suggest changes in any aspect of the services we provide
3. Civil rights. Your civil rights are protected by federal and state laws
4. Cultural/spritual/gender issues. You may request services from someone with training or experience from a specific cultural, spiritual, or gender orientation
5. Treatment. You have the right to take part in formulation your treatment plan
6. Denial of services. You may refuse services offered to you and be informed of any potential consequences
7. Record restrictions. You may request restrictions on the use of your protected health information; however, we are not required to agree with the request
8. Availability of records. You have the right to obtain a copy and/or inspect your protected health information; however, we are not required to agree with the request
9. Amendment of records. You have the right to request an amendment in your records; however, this request could be denied. If denied, your request will be kept in the records
10. Medical/legal advice. You may discuss your treatment with your doctor or attorney
11. Disclosures. You have the right to receive an accounting of disclosures of your protected health information that you have not authorized.
12. Medications used in your treatment. We will provide you with information descibing any potential risks of medications prescribed at our facility
13. Cost of services. We will inform you of the cost
14. Termination of services. You will be informed as to what behaviorsor violations could or did lead to termination of services at our clinic
15. Confidentiality. You will be informed of the limits of confidentiality and how your protected health information will be used.
16. Policy changes. You will be notified of any policy changes as they arise
17. We dedicate ourselves to serving the best interes of each client
18. We wil not discriminate between clients or professionals based on age, race, creed, ability, preferences,or other personal concerns
19. We maintain an objective and professional relationship with each patient
20. We respect the rights and views of other mental health professionals
21. We will appropriately end services or refer clients to other programs when appropriate
22. We will evaluate our personal limitations, strengths, biases, and effectiveness on an ongoing basis for the purpose of self improvement. We will continually attain further education and training.
23. We respect various institutional and managerial policies but will help to improve such policies if the best interest of the client is served
24. You are responsible for your financial obligations to the clinic as outlines in the Fee Schedule
25. You are responsible to treat staff and fellow patients in a respectful, cordal manner in which their rights are not violated
26. You are responsible to provide accurate information about yourself
Patient Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Gender Identity
Pronouns
Marital Status
Employer or School Name
Employer or School Address
Employer or School Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation or Position
Who referred you to our clinic?
Primary Care Physician Name
Primary Care Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Psychiatric Provider Name (if applicable)
Therapist Name (if applicable)
Therapist Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1: Full Name*
Emergency Contact 1: Relationship to Patient*
Emergency Contact 1: Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Insurance Carrier
Primary Insurance ID #
Primary Insurance Group #
Secondary Insurance Carrier (if applicable)
Secondary Insurance ID #
Secondary Insurance Group #
Patient Signature (for authorization)

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Date Signed

MonthDayYear
Date
Witness Signature (if required)

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Witness Date

MonthDayYear
Date
Have you been hospitalized in the last 5 years? If yes, please provide details.
Have you had problems with anesthesia? If yes, please describe.
Do you have allergies to any medications? Please list medications and reactions.
Do you use recreational drugs? Please provide details.
Do you use alcohol or over-the-counter/non-prescription drugs? Please describe.
Do you use tobacco or vaped tobacco? Please describe.
Do you use illegal drugs? Please describe.
Have you had any accidents or injuries in the last year? Please describe.
Have you experienced significant weight changes in the last year? Please describe.
Do you have sleep problems? Please describe.
Please describe your current living situation.
Are you experiencing relationship stressors? Please describe.
Current Medications (name, dosage, prescribing doctor)
Previous Medications and Reasons Discontinued

Please indicate if you or a family member has had any of the following conditions. Mark all that apply.

Rows	Self	Mother	Father	Siblings
Anxiety
Depression
PTSD/Trauma
Psychosis
Schizophrenia
Suicidality
Bipolar Disorder
Personality Disorder
Epilepsy
High Blood Pressure
Chronic Pain
Migraines
Aneurysm
Substance/Alcohol Abuse
Kidney Disease
Liver Disease
Heart Disease
Closed Angle Glaucoma

General Well-Being (e.g., fatigue, fever, weight loss)Gastrointestinal (e.g., nausea, vomiting, diarrhea)Immunological (e.g., allergies, frequent infections)Endocrine (e.g., excessive thirst, heat/cold intolerance)Ears/Nose/Throat (e.g., hearing loss, sore throat)Respiratory (e.g., cough, shortness of breath)Cardiovascular (e.g., chest pain, palpitations)Musculoskeletal (e.g., joint pain, muscle weakness)Neurological (e.g., headaches, dizziness, numbness)Psychiatric (e.g., anxiety, depression, mood swings)Other (please specify)

Patient Health Questionnaire (PHQ-9): Over the last 2 weeks, how often have you been bothered by any of the following problems?*

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

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

ASQ Suicide-Screening Questions*

Rows	No	Yes
In the past few weeks, have you wished you were dead?
In the past few weeks, have you felt that you or your family would be better off if you were dead?
In the past week, have you been having thoughts about killing yourself?

Have you ever tried to kill yourself? If yes, how? When?
Are you having thoughts of killing yourself right now? If yes, please explain

Generalized Anxiety Disorder (GAD-7): Over the last 2 weeks, how often have you been bothered by the following problems?*

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

If you checked any problems above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
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