Psychiatric Medication Management Program Application

Psychiatric Medication Management Program Application

Please complete this screening form to apply for our Focused Depression & OCD Medication Management Program. Applications are reviewed in the order they are received. Submission of this form does not guarantee enrollment in the program. Once your application has been reviewed by our clinical team, we will contact you with an update or let you know if any additional information is needed.
Patient Name (First and Last)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
Are you looking to transfer psychiatric medication management from another provider?
What are the reasons you are seeking medication management?
Are you seeking ADHD testing, ADHD evaluation, workplace/school accommodation documentation, or ADHD medication management?
Are you currently prescribed or requesting stimulant medication? (Examples: Adderall, Vyvanse, Concerta, Ritalin, Focalin, Dexedrine, or similar medications.)
Have you ever been diagnosed with any of the following? Check all that apply.
Have you ever experienced a manic episode? (Examples: needing very little sleep, feeling unusually energized or invincible, racing thoughts, impulsive or risky behavior, excessive spending, pressured speech, or others saying you were acting unlike yourself.)
Have you ever experienced hallucinations, paranoia, delusions, or a loss of contact with reality?
Have you ever been hospitalized for psychiatric reasons? If yes, please provide the number of hospitalizations, the date or approximate date of your most recent hospitalization, the reason(s) for hospitalization, and any other relevant information. If no, please enter N/A.
Are you currently taking psychiatric medication?
Are you currently using any non-prescribed medications or substances, such as cocaine or other recreational drugs?
If yes, how often?
Do you have any history of substance use disorder, detox, rehabilitation, or withdrawal?
Are you currently receiving treatment for substance use? (example Suboxone)
Do you have any history of homicidal ideation, or thoughts, intent, or plans to harm others?
Do you have any major medical conditions that may affect psychiatric medication treatment? Examples include seizures, stroke, heart attack, or heart rhythm abnormalities (arrhythmias). If yes, please describe the condition(s) and provide any relevant details.
Please check any of the Psychiatric medications you have tried in the PAST.
Please check any of the Psychiatric medications you are CURRENTLY taking
Additional Medication Information or Comments: Please use this space to provide any additional information about your current or previous medications that you feel may be helpful.
I understand that completing this screening does not guarantee acceptance into the Medication Management Program and that the program does not provide ADHD evaluation or ADHD medication management. I understand that the practice does not routinely initiate benzodiazepines for daily or long-term treatment and that continuation of an existing benzodiazepine prescription is not guaranteed. I understand that the practice generally does not prescribe stimulant medications concurrently with benzodiazepines due to safety concerns. I understand that I must disclose all controlled substance prescriptions to the clinic. I understand that medications should generally be prescribed within FDA guidelines unless an exception is approved by the Medical Director with documented clinical rationale.I understand that if my clinical needs fall outside the scope of the program, I may be referred to another provider or level of care.
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