TSM New Patient Intake: Dr. Pierce

First Name
Last Name
Date of Birth
Sex
Age
Phone
E-mail
Address
City
State
Address

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code
Race
Highest Level of Education
Occupation
Marital Status
Referral Source
Name of Emergency Contact
Phone Number

Rows	Yes	No
Are you depressed?
Do you consider yourself a worrier?
Have you ever been treated for alcohol or drug addiction?

What pharmacy will your prescription(s) be sent to?
Pharmacy Name
Address

Street Address

Street Address Line 2

CityState

Zip Code

Telepsychiatry Consent Form
Introduction

Telepsychiatry is the delivery of mental health services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. The interactive electronic systems used in Telepsychiatry incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

Potential Benefits
- Increased accessibility to psychiatric care.
- Patient convenience.
Potential Risks

As with any medical procedure, there may be potential risks associated with the use of Telepsychiatry. These risks include, but may not be limited to:
- Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for appropriate decision-making by your provider.
- Your provider may not be able to provide or arrange for emergency care that you may require.
- Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.
- Security protocols can fail, causing a breach of privacy of confidential health information.
Alternatives to the Use of Tele-psychiatry
- Traditional face-to-face sessions in your provider’s office.
Patient’s Rights
- I understand that the laws that protect the privacy and confidentiality of medical information also apply to Telepsychiatry.
- I have the right to withhold or withdraw my consent to the use of Telepsychiatry during the course of my care at any time. I understand that there may be no alternatives to telepsychiatry, based on location.
- I understand that my provider has the right to withhold or withdraw consent for the use of Teleppsychiatry during the course of my care at any time, based on clinical judgment of appropriateness.
- I understand that the all rules and regulations that apply to the provision of healthcare services also apply to Telepsychiatry.
Patient’s Responsibilities
- I will not record any Telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our Telepsychiatry sessions without my written consent.
- I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before the session begins.
- I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for Telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins.
- I understand that I must in eligible States to receive Telepsychiatry services from my provider.
My signature indicates that I have read the Telepsychiatry Consent Form

Naltrexone Information
In 1994, Naltrexone was FDA-approved for the treatment of Alcohol Dependence. Naltrexone blocks opioid receptors in the brain, preventing drinkers from experiencing the reinforcing effects of endorphins usually caused by alcohol.
Please check the boxes below to indicate that you have read each of the precautions.

Please take a photo of your valid identification, such as a Drivers License or Passport.

1. With the ID in focus, press the Green Camera icon in the lower right corner.

2. If you are satisifed with the image, press the same Green icon again to upload the image.

3. If you are not satisfied with the image, press the Red Redo icon on the lower left and take another photo.
Signature:The information I have provided is true to the best of my knowledge.
Date

MonthDayYear
Should be Empty:

Rows	Yes	No
Have you ever had counseling/therapy?
Have you ever attempted suicide?
Do you have a history of "cutting" or other self-injurious behaviors?
Have you ever been admitted to a psychiatric hospital?
Does alcoholism run in your family?
Have you ever been charged with DUI/DWI?

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 that you 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 hurting yourself in some way.

Rows	Not at all	Several days	Over 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"s hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful mighthappen

Rows	Never	More than a year ago	Less than a year ago
Tobacco
Alcohol
Marijuana
Cocaine
Methamphetamine
RECREATIONAL use of Opiates (Heroin, Oxycodone, Percocet, Vicodin, etc.)
Hallucinogens (LSD, Mushrooms, Peyote, DMT)
MDMA (Molly, Ecstasy)

Rows	Yes	No
Have you felt you should cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you felt bad or guilty about your drinking or drug use?
Have had a drink or drug first thing in the morning to steady your nerves or to get rid of a hangover?

Privacy and Office Polices

Telepsychiatry Consent Form

Naltrexone Information

Please take a photo of your valid identification, such as a Drivers License or Passport.