Christan Allison, PMHNP, Pre-Screening

Columbus Behavioral Health
An Association of Independent Practitioners

614.360.2600
Westerville | Dublin

Thank you for your interest in receiving medication mangement services with Christan Allison, PMHNP. To help her prepare for your appointment and determine whether she is the best fit for your needs, please answer the following questions as completely as you can.

Please note that Christan does NOT prescribe benzodiazepines, sleep medications, Suboxone/MAT or stimulant medications for ADHD.

We will call you within 7 days to either schedule an appointment or offer an alternate option for finding care. Make sure your voicemail box is not full so we are able to leave a message, if necessary, and be sure to check your messages.

Thank you.

Patient Information

Patient's Name

First NameLast Name

Are you a current patient at Columbus Behavioral Health?

If yes, which therapist here do you see?

Age (must be at least 18 years old)

Date of birth

Date

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance

PLEASE NOTE: We do NOT accept Anthem Blue Cross Blue Shield, Medicaid, CareSource, or UHC Community Plan (Medicaid). If you have one of these insurances, you will be SELF PAY.

What insurance will you be using or will you be self pay?

Insurance ID/Member Number (put n/a if self pay)

Who is the subscriber?

If you are on someone else's policy, please provide their name and date of birth. (leave blank if self pay)

Do you have secondary insurance?

If you have secondary insurance, provide name of insurance company, ID/member number, if you are the subscriber or are on someone else's policy, and if you are on someone else's policy, their name and date of birth

Questions

Please note that Christan does NOT prescribe benzodiazepines, sleep medications, Suboxone/MAT or stimulant medications for ADHD.

1. Current medications, including psychiatric medications, medications prescribed by other providers, and any over-the-counter supplements if relevant.

If you have more medications than fit above, please enter them here, including the name, dose, how often you take it, and what you take it for.

2. Mental health history/current symptoms: Please list any mental health or psychiatric diagnoses you have received in the past and describe the symptoms or concerns that are bringing you in for treatment.

3. History of Psychosis: Have you ever experienced symptoms such as hearing or seeing things that others could not, feeling that others were trying to harm or monitor you without evidence, or having beliefs that others considered unusual or not based in reality? If yes, please briefly describe when this occurred and whether you received treatment.

4. Alcohol and Substance Use: Please describe your current use of alcohol, marijuana/cannabis, nicotine, or any other recreational or non-prescribed substances. Include approximately how much you use and how often.

5. ADHD Treatment: If you are seeking evaluation or treatment for ADHD or attention concerns, please note that I do NOT prescribe stimulant medications. If you are interested in discussing non-stimulant treatment options, I would be happy to review whether those may be appropriate for you.

6. Medication Follow-Up: If we decide to begin medication treatment together, ongoing follow-up appointments are an important part of safe and effective care. Most patients are seen every 1–3 months, depending on their treatment plan, to monitor progress, address concerns, and continue medication prescriptions.

All patients must allow Christan Allison, PMHNP, to review their pharmacy records (for safety, prevention of drug interactions, duplication of medications, etc)

Signature

Screening Questionnaire