New Patient Intake Package

4400 East Highway 20, Suite #208, Niceville, FL 32578* Receptionist (850) 797-2598 * Nurse (850)797-1344 * Fax (773)492-8765
Reason for coming to Bluewater Behavioral Health*
Name (Last)*
Name (First, MI)*
SSN*
Date of Birth*

MonthDayYear
Date
Biological Sex*
Identity
Marital Status*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Currently Employed?*

YesNo
Place of employment?
Cell Phone #*
Email Address*
example@example.com
Emergency Contact Name*
Emergency Contact Phone #*
Are you applying for any type of disability or workers compensation?*

YesNo
If any, please describe your military background:
Branch
Years of Service
Active Duty or Retired

Active DutyRetired
Highest Level of Education Completed*
If patient is under 18 or not the insured party, please fill out the responsible party's information below:
Name (Last, First, MI)
Relationship to Patient
Date of Birth

MonthDayYear
Date
Address

Address (If different than above)

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Phone Number
Primary Insurance Carrier Or Cash?*
ID Number*
Sponsor Name (Last, First, MI)
Sponsor Date of Birth

MonthDayYear
Date
Secondary Insurance Carrier
ID Number
Sponsor Name (Last, First, MI)
Sponsor Date of Birth

MonthDayYear
Date
List ALL psychiatric and medical medications currently prescribed to you.
Medication Dosage   Times per day
Medication   Dosage   Times per day
Medication   Dosage   Times per day
Medication   Dosage   Times per day
Medication   Dosage   Times per day
None
Medication Allergies: Please list below any allergies to medications and the reaction.
Medication Reaction
Medication Reaction
Medication Reaction No No known drug allergies
Please list all past psychiatric medications taken and why you stopped taking it.
Medication Reaction
Medication   Reaction
Medication   Reaction
None
Please list substances you are using or have used in the past below.
Nicotine Intake: Do you smoke/vape?*

YesNo
If so, approximately how much per day?
How many years?
Caffeine Intake: Do you drink caffeinated beverages?*

YesNo
If Yes, How many per day?
Type of beverages typically consumed?

CoffeeTeaSodaEnergy DrinksOther
Alcohol Intake: Do you consume alcoholic beverages?*

YesNo
If so, how many per week?
Type of beverage typically consumed?
Do you, or have you, ever taken un-prescribed drugs, legal or illegal?*

YesNo
If so, what type?
Are you still using any of these?

YesNo
Which ones?
Past and Recent Psychiatric Providers:
Please list all current, recent and past mental health providers you have seen. Name Location
Name Location
Name Location
Name Location
Name Location
Name Location
Psychiatric Inpatient Hospitalizations:
Name Location   Date
Name      Location
Name   Location   Date
Known Psychiatric/Mental Health Diagnoses: Please check below any previously diagnosed mental health disorders.

DepressionAnxietyOCDPanic DisorderBipolarSubstance Use DisordersEating DisorderPTSDSchizophrenia Spectrum DisordersDissociative DisorderAnorexiaBulimiaPicaErectile DisorderSexual DisorderTic DisorderInsomniaNarcolepsyADHDHistrionic Personality DisorderAutism Spectrum DisorderConduct DisorderTourette's DisorderAgoraphobiaBorderline Personality DisorderDependent Personality DisorderMultiple Personality DisorderAdjustment DisorderAlzheimer's DiseaseDementiaBrief PsychosisDelusional DisorderGender DysphoriaHordingGambling DisorderPseudobulbar AffectCyclothymiaSchizoaffective DisorderDysthymiaBereavementTrichotillomaniaOther
Family Mental Health History: Please list diagnoses and family members with any known mental health disorders.
Name Diagnosis
Family Member Diagnosis
Family Member Diagnosis
Family Member Diagnosis
Family Member Diagnosis
Family Member Diagnosis
Current Primary Care Provider
Location (City)
Are you currently Sexually active?*

YesNo
If Yes, Are you trying to get pregnant?*

YesNoN/A
Personal Medical History Please check any condition below that applies to your personal medical history.

DiabetesHypertensionHigh CholesterolStrokeChronic PainGerd/Acid RefluxAllergic RhinitisCancerAsthmaCOPD/EmphysemaHypo/HyperthyroidismFibromyalgiaVision ProblemsArthritisIrritable Bowel DiseaseSleep ApneaCongestive Heart FailureHeart DiseaseParkinson's DiseaseSeizures/EpillepsyStrokeKidney Disease/FailureOther
Please list any past surgeries
Family Medical History Please list any family member diagnosed with any of the below medical conditions.
Diabetes
Hypertension
High Cholesterol
Asthma
Allergic Rhinitis
GERD/Acid Reflux
Sleep Apnea
Vision Problems
Arthritis
Fibromyalgia
COPD/Emphysema
Hypo/Hyperthyroidism
Vision Problems
Kidney Disease/Failure
Heart Disease
Seizures/Epilepsy
Cancer
Stroke
Parkinson's Disease
Other
Family member
Other
Family member
INFORMED CONSENT FOR MENTAL HEALTH EVALUATION/TREATMENT

I hereby voluntarily consent to mental health treatment. I understand that this may include psychiatric evaluation, medication management and/or psychotherapy either individually or with my family. I understand that my health information will be held private unless as described/outlined in the Privacyof Health Information Practices document I reviewed/received.
Initials*
Name I have been requested to participate in a court-ordered psychological evaluation/treatment program. The results of the evaluation or treatment progress will be reported to:
Are you currently involved in any court proceedings in which your medical records or provider's records and/or testamony may be requested?*

YesNo
I understand that if I have not had contact with the clinic and maintain continued care and follow-up appointments for more than 6 months it will be assumed as a mutual discharge from Bluewater Behavioral Health and may not be permitted to resume services.
Initials*
APPOINTMENT POLICY
APPOINTMENT POLICY

Thank you for choosing Bluewater Behavioral Health, Inc. We are committed to your successful treatment.

It is your responsibility to schedule follow-up appointments as directed by your provider or every 3 months at minimum, per the American Psychiatric Association guidelines, to ensure maintenance of your stability and/or medication refills. BBH makes every effort to ensure continuity of care including text reminders, phone call reminders and in-person verbal reminders in the clinic. Please note, appointment reminders are courtesy ONLY. You are responsible for knowing your appointment date and time. Due to HIPAA, patient specific names cannot be included in notifications.

If you are unable to make your scheduled appointment, we request you notify the clinic AT LEAST 24 HOURS/ONE BUSINESS DAY IN ADVANCE. If staff does not receive proper notification, the time scheduled with your clinician becomes a missed opportunity and delay for another patient to be seen. Failure to properly provide timely notification for missed/rescheduled appointments two or more times may result in discharge from services. I also acknowledge that I may be charged a no-show fee, as stated in the intake packet received. Fees may be charged to the card on file when no-shows occur. If a patient attempts to challenge the agreed upon charges and loses the challenge with the bank or credit card corporation, the patient will be charged an additional $50 dollar fee for administrative time and credit card charge-back fees.

Please note: appointment confirmations are a courtesy ONLY. You are responsible for your appointment date and time.

My initials acknowledge that I have read, fully understand and agree to all parts of this appointment policy.
Initials*
MEDICAID INSURANCE
Bluewater Behavioral Health is not a Medicaid participating provider. Thereby, it is illegal for Bluewater Behavioral Health to see patients who have Medicaid insurance benefits.

Signature* _ I hereby attest that I do not qualify for any Medicaid benefits or have Medicaid insurance coverage.
FINANCIAL POLICY
All payments (i.e. co-pays, co-insurance, deductibles) ARE DUE AT TIME OF SERVICE. Payments are accepted in the form of cash, check, money order, and credit card (Visa, Mastercard, Discover, American Express Accounts must remain in good standing to continue receiving treatment at Bluewater Behavioral Health. In the event that your insurance denies your claim, you will be charged the cash pay rate for the appointment. Additional charges due once remittance is received will be charged to the card on file. All unpaid balances must be paid before making additional appointments. Cash fee rates are as follows. Intake or 1 Hour follow-up = $250, Follow-up 30 minute appointment $175, 15 Minute Consult $85, Med refills without appointment $25. Fee changes are at the discretion of the provider.

A $30.00 service fee will be added to your account for each returned check. Only cash payment will be accepted if two NSF

Refunds or overpayment reimbursements are only made after full insurance reimbursement and patient responsibility is paid in full for all services rendered on your account.
Medications may not be refilled due to failure to make a follow-up appointment, cancellation, rescheduling or no-show appointments. I understand that I may not be rescheduled or provided refills if my account balance exceeds $50.

Initial Below
Initials*
I understand if I do not attend my scheduled follow-up appointment and fail to notify the office at least 24 hours/1 Business day in advance, I may be charged a $65 no-show/late cancellation fee per first follow-up visit missed. Additional no-show/late cancellations will be charged $85. The first missed intake appointments will be charged $100, and may result in denial of future treatment/appointments. A second missed intake appointment will be charged $200. Two or more no-shows/late cancellations may result in termination of treatment. All no-show/late cancellation therapy appointments will result in a $100 Fee. Fee will be charged to card on file at time of appointment. Fee is not applicable to VA patients.

Initial Below
Initials*
I have read, fully understand and agree to all parts of this financial policy. I understand that my account may be turned over to a collection agency if it becomes delinquent.

Initial Below
Initials*
PATIENT BEHAVIOR POLICY
I understand effective clinical relationships are founded on mutual respect. In the event that a patient or family member violates this principal, they will be given a warning which will be documented in the patients chart. Further violations will result in the immediate discharge for cause from the clinic.

Initial Below
Initials*
PRIVACY OF HEALTH INFORMATION PRACTICES CONSENT
You may request a paper copy, or obtain a copy from the office website: www.bluewaterbehavioralhealth.com.Bluewater Behavioral Health and staff can communicate via e-mail on matters related to your health and/or your treatment. We also invite you to participate in our online reminder system and patient portal through OnPatient. Features include:

❖ Receive text messages and auto phone call appointment reminders

❖ Confirm appointments via email

❖ Request appointments online
I want to receive text messages and auto phone reminders.*

YesNo
I want to receive and communicate through email*

YesNo
I understand that any confidential health information that I send to the practice is not secure and is sent at my own risk. I will not hold the practice, nor any of its workforce members, liable for loss of any confidentiality associated with information transmitted via email or

I also understand if I utilize an email provider that does not use encryption technology the information included may not be secure.I acknowledge this risk and will not hold the practice or any of its workforce members liable for any loss of confidentiality associated with

If you believe your privacy rights have been violated, you can file a complaint with the Director of Health Information Management or with the Secretary of Health Services. There will be no retaliation for filing a complaint.

My signature acknowledges that I have read, fully understand and agree to all parts of this privacy policy.
Signature*

Clear
Patient is a minor or is unable to provide consent because - Type a label
My relationship to the patient is
Patient or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

APPOINTMENT POLICY

MEDICAID INSURANCE

FINANCIAL POLICY

PATIENT BEHAVIOR POLICY

PRIVACY OF HEALTH INFORMATION PRACTICES CONSENT