New Patient Intake Form - Evolve

Intake Form

PHQ-9/GAD-7/HIPAA/Financial Responsibility
Submission Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Patient Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Financial Responsibility Form
Date

MonthDayYear
Date
Patient Name:

First NameLast Name
Re: Financial Responsibility
I Understand that although Priyadarshan Bajpayi MD PC d.b.a Evolve Psychiatry accepts my medical insurance, and will be submitting claims for my visits to the insurance company for payment. If for any reason the claims are denied or not paid by the insurance company, I am personally responsible for final payment for any services rendered at this facility.
This card I will be leaving on file will be applied to any Tele-health or phone call appointment co-pays. I understand if I plan to participate in Tele-health or phone call appointments, it is required that I leave a credit card on file to be charged at the time of every appointment.
Additionally, if for some future reason I do not meet my financial obligation I give Priyadarshan Bajpayi MD PC d.b.a Evolve Psychiatry permission to charge the credit card I will leave on file, up to $350 for services rendered. I understand that if I fail to pay two or more co-pays, at the time of my visit I will not be able to be seen by my provider. Please sign as acknowledgement. Signature
PHQ-9
Date of Exam*

MonthDayYear
Date
Patient Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date

Over the last 2 weeks, how often have you been bothered by the following problems?*

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

GAD-7
Feeling Nervous,anxious or on edge?*

0-Not at all sure1-Several Days2-Over half the days3-Nearly every day
Not Being able to stop or control worrying?*

0-Not at all sure1-Several Days2-Over half the days3-Nearly every day
Worrying too much about different things?*

0-Not at all sure1-Several Days2-Over half the days3-Nearly every day
Trouble Relaxing?*

0-Not at all sure1-Several Days2-Over half the days3-Nearly every day
Being so restless that it's hard to sit still?*

0-Not at all sure1-Several Days2-Over half the days3-Nearly every day
Becoming easily annoyed or irritable?*

0-Not at all sure1-Several Days2-Over half the days3-Nearly every day
Feeling afraid as if something awful might happen?*

0-Not at all sure1-Several Days2-Over half the days3-Nearly every day
MDQ
1. Has There ever been a period of time when you were not your usual self and...
You felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got in trouble*

YesNo
You were so irritable that you shouted at people or started fights or arguments*

YesNo
You felt much more self-confident than usual*

YesNo
You got much less sleep than usual and found you didn't really miss it*

YesNo
You were much more talkative or spoke much faster than usual*

YesNo
Thoughts raced through your head or you couldn't slow your mind down*

YesNo
You were easily distracted by things around you that you had trouble concentrating or staying on track*

YesNo
You had much more energy than usual*

YesNo
You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night*

YesNo
You were much more interested in sex than usual*

YesNo
You did things that were unusual for you or that other people might have thought were excessive, foolish or risky*

YesNo
Spending money got you or your family into trouble*

YesNo
2. If you said yes to more than one of the above, have several of these ever happened during the same period of time*

YesNo
3. How much of a problem did any of these cause you -like being unable to work;having family,money or legal troubles;getting into arguments or fights*

No ProblemMinor ProblemModerate ProblemSerious Problem
Have any of your blood relatives(i.e children,siblings,parents,grandparents,aunts,uncles) had manic-depressive illness or bipolar disorder*

YesNo
Had a health professional ever told you that you have manic-depressive illness or bipolar disorder*

YesNo
HIPPA(If you have no one you would like us to be able to discuss your treatment with enter N/A in field 1, check off the rest of the boxes, and sign.) Thank you!
1. Authorization I authorize _Priyadarshan Bajpayi MD. PC. and Associated Providers/Clinicians_ (healthcare provider) to use and disclose the protected health information described below to:*
PCP, family, therapist, (individual seeking the information)
2. Effective Period This authorization for release of information covers the period of healthcare from:*

all past, present, and future periods.
3. Extent of Authorization*

I authorize the release of my complete health record
(including records relating to mental health care,and treatment of alcohol or drug abuse).
4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. 5. This authorization shall be in force and effect until ___Terminated from treatment or Discharged___, at which time this authorization expires. 6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. 7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. 8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Signature*

Clear
Signature of patient or personal representative
Should be Empty: