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Microsoft word - intake.docx

Lowcountry Psychiatric Associates
Intake Form

Name______________________________ DOB____________ SSN_______-_____-_________
Emergency Contact: _________________ relation: ____________ Tel.# ______________________
Referred by _________________________ Primary Physician _____________________
What are the problem(s) you are seeking help for today?
____________________________________________________________________________________
____________________________________________________________________________________
Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms)
( ) Depression

Suicide Risk
Have you ever tried to harm yourself in the past? ( ) Yes ( ) No.
Have you had any recent thoughts, or do you currently have any thoughts of suicide? ( ) Yes ( ) No.
Medical History:
Allergies____________________________ Current Weight ____________ Height ____________

List ALL current prescription medications
and how often you take them/dosage:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Current over-the-counter medications or supplements:
_____________________________________
Current/Past medical problems, hospitalizations or surgeries:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

For women:
Date of last menstrual period: _______Are you currently, or do you think you are pregnant?( )Yes( ) No.
Are you planning to get pregnant in the near future? ( ) Yes ( ) No
Family History (Medical/Psychiatric Diagnoses, Substance Abuse Or Self-Injury/Suicide):
____________________________________________________________________________________
____________________________________________________________________________________
Past Psychiatric History
Outpatient treatment
( ) Yes ( ) No. If yes, Please describe when, by whom, and nature of treatment.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Psychiatric Hospitalization ( ) Yes ( ) No If yes, describe for what reason, when and where.
____________________________________________________________________________________
____________________________________________________________________________________

Past Psychiatric Medications:
If you have ever taken any of the following medications (please circle).
Mood/Thoughts: Prozac, Zoloft, Luvox, Paxil, Celexa, Lexapro, Viibryd, Effexor, Cymbalta,Wellbutrin, Remeron, Serzone,
Anafranil, Pamelor,Tofranil, Elavil, Tegretol, Lithium, Lamictal, Tegretol, Topamax, Seroquel, Zyprexa, Geodon, Abilify,
Clozaril, Haldol, Prolixin,
Sleep: Ambien, Lunesta, Sonata, Rozerem, Restoril, Desyrel/trazodone
ADHD: Adderall, Concerta, Ritalin, Vyvanse, Focalin, Dexedrine, Strattera
Anxiety: Xanax, Ativan, Klonopin, Valium, Restoril, Librium,Tranxene, Buspar, Vistaril, Benadryl, Propranolol
Other: _____________________________________________________________________________
Any negative/positive experiences with these medications?
____________________________________________________________________________________
____________________________________________________________________________________

Substance Use:
Do you (or others) think you may have a problem with alcohol or drug use? ( ) Yes ( ) No
Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No
If yes, for which substances and when/where were you treated? ________________________________
Days/wk drinking alcohol: _____ Avg. Number drinks/day: _________ Most drinks/day: _______
Do you have current/past problems with the use/abuse of illegal substances? If so, which substances?
____________________________________________________________________________________
Have you abused prescription medication? If so, which medications? ____________________________
How many caffeinated beverages do you drink a day? Coffee _____ Sodas ________ Tea ___________
Tobacco/Cigarette History: _____________________________________________________________
Family Background and Childhood History:
Were you adopted? ( ) Yes ( ) No Where did you grow up?____________________________________
List your siblings and their ages: _________________________________________________________
Did your parents’ divorce? ( ) Yes ( ) No If so, how old were you when they divorced? ______________
If your parents divorced, who did you live with? ____________________________________________
Educational History:
What is your highest educational level or degree attained? _____________________________________
Spiritual life: Do you belong to a particular religion or spiritual group? __________________________
Trauma History:
Do you have a history of being abused emotionally, sexually, physically or by neglect? ( ) Yes ( ) No.
Please describe when, where and by whom.
____________________________________________________________________________________
____________________________________________________________________________________

Occupational History:
Are you currently: ( ) Working ( ) Not working by choice ( ) Unemployed ( ) Disabled ( ) Retired
What is/was your occupation? ___________________________________________________________
Have you ever served in the military? _______ If so, what branch and when? _____________________
Relationship History and Current Family:
Are you currently: ( ) Married ( ) Divorced ( ) Single ( ) Widowed
How long? _____ Total number of marriages?______
If not married, are you currently in a relationship? ( ) Yes ( ) No If yes, how long? ________________
Are you sexually active? ( ) Yes ( ) No
How would you identify your sexual orientation?
( ) heterosexual ( ) homosexual ( ) bisexual ( ) transsexual
Do you have children? ( ) Yes ( ) No. If yes, list ages and gender________________________________
Legal: Have you ever been arrested? _______ Do you have any pending legal problems?____________
____________________________________________________________________________________
OFFICE POLICIES

PHONE CALLS/AFTER HOURS CALLS/TELEPHONE CONSULTATIONS: We typically return
routine/non-urgent phone calls within the same business day if the message is left within normal business hours.
Our policy is to provide quality patient care through scheduled office visits, not unscheduled phone calls, and we
may direct you to make an appointment. If it is an urgent matter, you may dial our after hours number
(866.256.4501; also found on website & main office voice mail) to contact a provider. After hours phone calls in
excess of five minutes will be charged a rate consistent with office time, and are usually not covered by insurance.
EMERGENCIES:
In the event of any emergency, please go to the nearest emergency room or call 911 immediately. You may also
contact your provider through the after hours line, after taking the step above.

MEDICATION REFILLS:
Please recognize when you are short on medication and call your pharmacy. Often patients have refills on file. If
not, ask the pharmacy to fax the office a medication refill request for your doctor to review. It is best to notify
your pharmacy at least 5 business days before you would run out of medication. If you call the office needing
refill of medication within 48 hours, you will be charged $25.
MISSED/LATE APPOINTMENTS:
Missed appointments not canceled within 24 hours notice will be charged. Charges for missed appointments are
usually not covered by insurance.
MEDICAL FORMS/PATIENT REQUESTED LETTERS:
Charges to complete medical forms and patient requested letters are not usually not covered by insurance
companies and are the responsibility of the patient. Fees may vary according to the length and complexity of the
form or requested letter. Payment is due prior to picking up or mailing the requested document.

PAYMENT
Walters,MD/Ford, MD
If am being treated by Joseph Walters, MD or Richard Ford, MD:
* I understand, they are NON-PARTICIPATING in my insurance plan, including MEDICARE/MEDICAID.
* I agree to accept full responsibility for payment of fees incurred at the time of each visit.
* I will be made available necessary billing/procedure codes for the type of treatment I receive from Dr.
Walters/Ford, which can be submitted to my insurance carrier for any reimbursement for which I may be eligible.
Scott, LPC If I am being treated by Catherine Scott, LPC:
*If I am 'self-pay', payment will be due at the time service is rendered.
*If I have insurance, I acknowledge that LPA may disclose protected health information to my insurance carrier
or other third party responsible for my bill as required in order to receive reimbursement for services provided.
* Medical Insurance: We strongly urge you to thoroughly review your insurance plan prior to your appointment.
The type of plan chosen by you and/or your employer determines your insurance benefits. We will electronically
(or paper) file your medical insurance claims and bill your medical insurance for treatment you receive. However,
in the event the insurance company does not pay the bill, the balance will become the patient’s responsibility.
*I authorize and request assignment of benefits to be paid directly to LPA. I acknowledge and agree to pay any
unpaid balances not covered by my insurance policy, including deductibles, co-payments, and unauthorized or out
of network services. Copayments and deductibles are to be paid at each appointment.
*Our staff is happy to help with insurance questions related to how a claim was filed, or regarding information the
carrier may need to process a claim. Specific coverage issues, however, can only be addressed by your insurance
company. Please contact Customer Service at the number listed on your insurance card.
PROFESSIONAL FEE SCHEDULE:
Psychiatry/Therapy (FORD/WALTERS,MD)
45-50 min session (psychotherapy +/- meds) = $175 20-25 min session (brief therapy/med management) = $120 10 min session (medication check up) = $90
DELINQUINT FEES:
Fees are expected to be paid at the time of service, unless prior arrangements have been made through the front
office.
PRINT NAME: _____________________________ SIGNATURE: ______________________________ DATE: ___________________________________

Source: http://www.lowcountrypsych.com/upload/intake.pdf

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