Balanced Minds and Wellness Patient Intake Form
Please complete all required fields prior to your appointment. Incomplete paperwork may delay your visit.
Reason for today's visit
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Personal Information
Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Sex Assigned at Birth
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Male
Female
Marital Status
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Single
Married
Divorced
Separated
Widowed
Other
Visit Type
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Telehealth
In-Person
What state are you currently located in for this visit?
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Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
I confirm that I am physically located in a state where my provider is legally authorized to provide telehealth services at the time of this visit (for example: Mississippi or Colorado)
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Yes
No
Contact Information
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Best Method of Contact
*
Please Select
Cell Phone
Home Phone
Email
Address Line 1
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Address Line 2
City
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State
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Zip Code
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Payment and Insurance Information
Method of Pay
*
Cash Pay
Insurance
Insurance Company Name
Member ID
Group Number
Subscriber Name (if not self)
Relationship to Patient
Pharmacy Information
Preferred Pharmacy Name
*
Pharmacy Address
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Street Address
City
State / Province
Postal / Zip Code
Medical History
Medications
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Allergies(Food, Drugs, Environmental)
*
Past Medical History
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None
Hypertension
Diabetes
High Cholesterol
Heart Disease
Asthma
COPD
Thyroid Disorder
Migraines
Chronic Pain
Arthritis
GERD/Reflux
Kidney Disease
Anxiety
Depression
ADHD
Bipolar Disorder
PTSD
Insomnia
Substance Use
Cancer
HIV/AIDS
PCOS
Other
Do you currently have a primary care provider?
*
Please Select
Yes
No
May we communicate with your primary care provider regarding your care if necessary?
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Yes
No
If yes, please provide the name of provider.
May we obtain records from previous providers if necessary for your care?
*
Please Select
Yes
No
Have you had thoughts of harming yourself or others within the past 30 days?
*
Please Select
Yes
No
Family and Social History
Family History
*
None
Hypertension
Diabetes
Heart Disease
Stroke
High Cholesterol
Cancer
Thyroid Disorder
Asthma
Kidney Disease
Anxiety
Depression
Bipolar Disorder
ADHD
Schizophrenia
Substance Abuse
Other
Social History
*
None
Tobacco Use
Vaping
Alcohol Use
Recreational Drug Use
Caffeine Use
Exercise Regularly
Sexually Active
Lives Alone
Employed
Student
History of Abuse/Trauma
Other
Consents and Policies
Consent to Treat: I voluntarily consent to evaluation, diagnosis, and treatment provided by Balanced Minds & Wellness, PLLC and its healthcare providers. I understand that medical and mental health services may include examinations, assessments, testing, treatment recommendations, prescriptions, and follow-up care. I understand that no guarantees or assurances have been made regarding the outcome of treatment. I acknowledge that I have the right to ask questions regarding my care and that all questions have been answered to my satisfaction. I authorize Balanced Minds & Wellness to obtain and release medical information as necessary for treatment, payment, healthcare operations, and coordination of care in accordance with HIPAA regulations. I understand that I may refuse treatment or withdraw consent at any time, but doing so may affect my ability to receive continued care.
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Yes
No
Telehealth Consent: I confirm that I will be physically located in a state where my provider is authorized to practice at the time of my telehealth visit. I understand that telehealth services may not be available if I am located in a state where my provider is not authorized to provide care.I consent to participate in telehealth services provided by Balanced Minds & Wellness, PLLC using secure electronic communication technology. I understand that telehealth involves the use of audio, video, and electronic communications to allow healthcare providers to evaluate, diagnose, educate, monitor, and treat patients remotely.I understand that there may be limitations to virtual visits compared to in person evaluations and that technical difficulties may occur during appointments. I understand that my provider may not be able to diagnose or treat all conditions through telehealth and may recommend an in person evaluation, urgent care visit, emergency treatment, or referral when clinically appropriate.I understand that my privacy will be protected to the best extent possible using secure systems and that I am responsible for participating in visits from a safe and private location whenever possible.I understand that if my provider determines that my condition requires emergency or in person care, I may be directed to seek immediate medical attention, urgent care, or emergency services. I acknowledge that I may withdraw my consent for telehealth services at any time.
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Yes
No
HIPAA Acknowledgement: I acknowledge that I have received or been given access to the Notice of Privacy Practices for Balanced Minds & Wellness, PLLC. I understand that this notice explains how my medical information may be used and disclosed and outlines my rights regarding protected health information under HIPAA regulations. I understand that Balanced Minds & Wellness may use and disclose my health information for purposes of treatment, payment, healthcare operations, and other uses permitted or required by law.
*
Yes
No
AI-Assisted Documentation Consent: I understand that my provider may use HIPAA-compliant artificial intelligence (AI) technology to assist with documenting medical visits. This technology is used to help create accurate clinical notes and does not replace the provider's medical judgment. All documentation is reviewed and approved by the provider before becoming part of the medical record.
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Yes, I consent to AI-assisted documentation during my visits
No, I do not consent to AI-assisted documentation during my visits
Financial Policy Acknowledgement: I understand that payment is due at the time services are rendered unless prior arrangements have been made. I understand that Balanced Minds & Wellness may collect copays, deductibles, coinsurance amounts, self pay balances, and fees for services not covered by insurance. I understand that appointment fees cover the provider evaluation and management service. Additional medically necessary testing, laboratory services, procedures, injections, medications, supplies, forms, and administrative services may result in additional charges. I understand that missed appointments, late cancellations, forms completion, and certain administrative services may result in additional fees. I acknowledge that insurance verification does not guarantee payment by my insurance company and that I am ultimately responsible for any balance not paid by insurance. I understand that superbills may be provided for out of network reimbursement when applicable; however, reimbursement is not guaranteed
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Yes
No
Payment Authorization: I authorize Balanced Minds & Wellness, PLLC to charge my payment method on file for copays, deductibles, coinsurance, self pay balances, missed appointment fees, and charges for services rendered in accordance with the Financial Policy.
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Yes
No
Laboratory Services Acknowledgement: I understand that laboratory testing may be performed by an independent laboratory. Laboratory charges may be billed separately and may not be included in the office visit fee. Any costs associated with laboratory services are the responsibility of the patient subject to insurance coverage and laboratory billing policies.
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Yes
No
Assignment of Benefits: I authorize payment of insurance benefits directly to Balanced Minds & Wellness, PLLC for services rendered. I authorize the release of medical information necessary to process insurance claims and obtain payment for services provided.
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Yes
No
No Show Policy Acknowledgement:I understand missed appointments or cancellations with less than 24-hour notice may result in a fee.
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Yes
No
Communication Consent: I consent to receive appointment reminders, calls, emails, and text messages from Balanced Minds & Wellness regarding my care.
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Yes
No
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