Sunstone Psychiatric Initial Interest Form

Initial Interest Form

Currently Annie Hood, PMHNP-BC, Dr. Marla Castello, and Dr. Katie Spira are accepting new clients for medication management. Our therapists are not accepting new patients at this time. If you have interest in getting on a provider's wait-list, please continue to complete this form. If you believe your provider has referred you to a specific clinician, please ask them to be in touch regarding individual availability.
For Office Use Only
This field will be used by clinic staff to communicate assessment info
Reviewed by Clinician name on Date . Clinical Comments:Schedule with , notes.
Send to for approval (remember to click "Update")

Sara WeberJoey De Armond-ReidAnnie HoodDominique du BoisKendra BeckerMarla CastelloKatie Spira
Contact notes:
Confidential Patient History Form

Once received, your form will be reviewed by our clinical team as soon as possible (currently within 2-3 weeks) and we will call to schedule or provide appropriate referral. Please make sure your voicemail is set-up and not full. If you have any questions or concerns you may always contact us via telephone at 503-477-7878.
Full name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
Your Mobile Phone Number*

Area CodePhone Number
Your Home Phone Number

Area CodePhone Number
Emergency contact*

First NameLast Name
Relationship to self
Ex Family friend, Mother, Sister, etc
Emergency Contact's Mobile Phone number*

Area CodePhone Number
Preferred Pharmacy:

Employment and Insurance
Occupation
Employer
Please upload a photo of the front and back of your insurance card below, if applicable. If you are working on a computer, you may use the file drop to upload photos instead.
Browse Files

Cancelof
Please note: We do not bill secondary insurance. If you have secondary coverage, we can provide a superbill for you to submit for reimbursement.

Mental Health Treatment History
Have you every been diagnosed with a mental health condition by a licensed clinician? If yes, please list:*
Outpatient Treatment such as counseling, or therapy?
If yes, please describe when, by whom, and nature of treatment:
Psychiatric Hospitalization:*
Please provide facility name, dates and duration, if possible
Intensive outpatient or partial hospitalization treatment:*
Past mental health medications: Please indicate the dates, dosage, and how helpful they were/your response/side effects. If you can't remember details, just write what you remember. If you have never used mental health medicine, just say none*
Have you ever had feelings or thoughts that you didn't want to live?*
Have you ever tried to kill or harm yourself before?*
Do you have access to guns?*
Do you feel safe at home? in your relationships?*

Current Treatment Team
Where did you hear about Sunstone Psychiatric?
Please name the person who referred you (if applicable) and provide contact information if appropriate.
Do you have a therapist/counselor? If yes, please provide their name and phone number
Do you have a primary care provider? If yes, please provide their name and phone number
Do you see any other providers regularly (naturopath, acupuncture, herbalist, pain management clinic, neurologist, rheumatologist, allergist, etc)? If yes, please list their name, speciality, and phone number.
By signing below you give permission for ongoing regular updates to be provided to your treatment team. This will help
assure the highest standard of care.

Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your
name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the
conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18
years old have your parent or legal guardian sign the waiver.
Signature*

Clear
Date*

MonthDayYear
Date

Credit Card Authorization for No Shows, Late Cancellations and other fees

In order to provide you and other patients of Sunstone Psychiatric, LLC the best possible care, a minimum of 48 hours notice is required to cancel or reschedule your regular appointments and five business days for initial evaluation appointments.

By signing this form, I understand a deposit of $400 may be charged to my credit card to hold my initial intake appointment. This may be refundable once insurance coverage has been successfully established and payment arrangements made. If initial visit is canceled without five business days notice, this deposit is non-refundable. Additional deposit may be required to reschedule an intake appointment canceled without adequate notice. Your credit card information will be obtained when scheduling your first visit.

By signing this form, I understand the importance of notifying my provider at least 48 hours prior to my scheduled appointment if I am not able to keep my appointment. If I am experiencing an emergency, I will provide as much notice as possible to avoid being charged the late cancellation fee of $150. I understand that I will be charged a no-show fee of $200 for failing to call and failing to show for my scheduled appointment. A no-show can be grounds to terminate treatment.

By signing this form, I give Sunstone Psychiatric, LLC the authorization to charge my credit/debit card on file $150 for each missed or rescheduled appointment where 48 hours notice is not given and $200 for each missed appointment where I fail to call and do not show for the appointment. This credit card will also be used for all fees that have not been paid within 30 days (unless other arrangements for payment have been agreed upon between me and my provider). A receipt is available upon request.

For outstanding payment of service rendered, I otherize Sunstone Psychiatric, LLC to charge my credit card for the full amount due. I will not dispute for sessions I have received, or that I have not canceled fewer than 48 hours in advance.

I also authorize Sunstone Psychiatric, LLC to disclose information about my attendance/cancellation to my credit card company if I dispute a charge. I acknowledge that I am aware there is a $25 fee for any declined credit card charge.

I agree that the credit/debit card may also be used for payment of services (co-payment, deductibles, coinsurance, paperwork, and other applicable fees). I understand that I may revoke this agreement at any time by providing a request in writing.

Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Not at all	Some of the days	Most of the days	Nearly all of the days
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 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 so fidgety or restless that you have been moving a lot more than usual?
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

	Not at all (0)	Some of the days (1)	Most of the days (2)	Nearly all of the days (3)
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 is hard to sit still?
Becoming easily annoyed or irritable?
Feeling afraid, as if something awful might happen?

	Never	Rarely	Sometimes	Very Often
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have timeto yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

	Yes	No
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 into trouble?
…you were so irritable that you shouted at people or started fights or arguments?
…you felt much more self-confident than usual?
…you got much less sleep than usual and found you didn’t really miss it?
…you were much more talkative or spoke faster than usual?
…thoughts raced through your head or you couldn’t slow your mind down?
…you were so easily distracted by things around you that you had trouble concentrating or staying on track?
…you had much more energy than usual?
…you were much more active or did many more things than usual?
…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
…you were much more interested in sex than usual?
…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
…spending money got you or your family in trouble?
2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

	Yes	No
SKIN - lesions, eczema, psoriasis, skin cancer, moles or rashes, other?
ENDOCRINE - diabetes, hypoglycaemia, thyroid, pancreas, other?
GASTROINTESTINAL - ulcers, hiatus hernia, reflux, diverticulitis, diarrhoea, IBS, other?
BLOOD -anemia, thrombosis, anticoagulants, leukaemia, other?
LIVER - hepatitis, jaundice, liver disease/dysfunction, other?
MUSCULOSKELETAL -serious injury, accident, disorders of the back, deformity, loss of strenth, pain, arthritis, other?
NEUROLOGICAL - weakness, numbness, other neuropathy, stroke, seizures, neurological disease genetic or acquired, migraine, traumatic brain injury, other?
RESPIRATORY - asthma, COPD, shortness of breath, CF, emphysema, sleep apnea, other?
HEART - rheumatic fever, valves, heart attack, murmur, hypo or hypertension, angina, congestive heart failure, malformation, arrhythmias, other?
KIDNEY - kidney eg CKD, nephrotic syndrome, bladder, prostate, dialysis other?
INFECTIOUS OR CONTAGIOUS DISEASE - HIV, hepatitis, Covid, other?
CANCER - unexplained weight loss, treatment for cancer
SURGICAL PROCEDURES - excisions, replacements, repairs, trauma, cosmetic, lifesaving, other?
ALLERGIES - are you allergic to any medications, latex, foods, plasters, if you carry an epipen give details below.
DO YOU HAVE ANY SIGNIFICANT GENETIC OR OTHER DISEASE WITHIN YOUR BLOOD RELATIONS - eg HTN, CKD, Heart Disease, Huntington's disease, diabetes mellitus, other? Please elaborate Below
DO YOU HAVE ANY FAMILY HISTORY OF MENTAL HEALTH CONCERN - eg anxiety, depression, bipolar affective disorder, schizophrenia, personality disorder, trauma, anger issues, substance abuse issues? Please elaborate below
VISION - macular degeneration, DM retinal disease, glaucome, other?

Initial Interest Form

Confidential Patient History Form

Employment and Insurance

Mental Health Symptom Questionnaire

Mental Health Treatment History

Health Screening Questionnaire

Developmental History

Social History

Current Treatment Team