Why utilize a Psychiatric Mental Health Nurse Practitioner

Financial Policy

Thank you for choosing us as your care provider. We are committed to providing you with quality and affordable healthcare. This billing process notification is developed to assist you with understanding your rights and responsibilities when receiving services with SMHWI.

Insurance: SMHWI Participates in most insurance plans, including Medicare. If you are not insured by a plan, payment in full is expected at each visit. If you are covered by a participating plan, but you are either missing an updated insurance card or cannot provide policy and group number, you will be responsible. You will be required to pay for your visit in full until our office is able to confirm your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

Proof of insurance: All Patients must confirm and/ or complete a patient information form before being seen. We must obtain a copy of your driver's license and current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner (48 hours before appt), you will be responsible for the balance of the claim.

Non- Covered Services: Please be aware that some- and perhaps all- of the services you receive may be non covered or not considered reasonable or necessary by your insurers. You will be billed for these services.

Change in insurance plans: You are expected to notify our office if your insurance coverage changes. We will ask you to update your record at each visit to our office. It is also your responsibility to notify the office immediately of these changes. Balances left over 90 days will become the responsibility of the patient. Insurance carriers give us a 90 day period to submit claims to them for payment. After that time it will be denied as past timely filing. If we are unable to process your claim due to incorrect information given, we will bill you directly for services.

Claims Submission: We will submit your claims and assist you in any way reasonable to help get your claim paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. If payment is denied due to lack of response from you, the balance will immediately become due and payable by you. Your insurance benefit is a contract between you and your insurance company. We are not the party to the contract.

Payment is Required at The time of Service: Patients who are not covered by health insurance, on a plan that we do not participate with , or if we are not able to verify your coverage must pay at the time of service. Patients who have plans that we do participate with are asked to pay their co-payment, coinsurance, deductibles, or non-covered services at the time of their visit.

Self Pay: We want to provide uninsured patients with quality and affordable healthcare. Most of our billed charges will be discounted for self- pay patients. In order for us to offer these rates, payments must be made in full at the time of service before leaving the office. No further discounts will be given. This discount does not apply if insurance is or has been billed. The self pay discount does not apply to Co-pays, deductibles, or non covered services.

Nonpayment: Should your account become 90 days delinquent, you will receive a letter stating that you have 10 days to pay your account in full. Patient payments will not be accepted unless otherwise negotiated with a member of our billing team. Please be aware that if a balance remains unpaid, we will refer your account to a collection agency. The patient or guarantor will be responsible for all costs of collection including attorney fees, collection fees and contingent fees to collections agencies of not less than 35 percent. The contingency fees will be added and collected by the collection agency immediately up to our referral of your account to the collection agency of our choice.

Third Party Billing- We do not do any third party billing, follow up or related activity. If a third party may be involved, it will be the patient’s responsibility to seek reimbursement. Patients involved with a third party payor will be expected to provide health insurance or if uninsured, will fall under the self pay guidelines.

Our practice is committed to provide the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.

Thank you for understanding our financial policy. Please Let us know if you have any questions.

I have read and understand the financial policy and agree to abide by its guidelines.

Name Patient:

Have you abused prescription drugs?

Phone:

Email:

Printed Name of Patient:

Documentation

Upload front and back of insurance card, ID/Driver's License, and custody documentation if applicableduplicate 8
**(Patients using insurance for appointments will have to provide a copy of the front and back of insurance card prior to scheduling)duplicate 8**

Please select the documents you wish to send
IDDriver's LicenseInsurance Cards

Please, ensure that the files that you are attaching for submission do not exceed the maximum size of 10 MB. Files larger than this might cause that your files do not get to our offices along with your information.
If you do not have this any of these files in digital, you can bring them to your first consultation with our doctors.

Front Copy DL:

Upload your Files

Back Copy DL:

Upload your Files

Front Copy Photo ID:

Upload your Files

Back Copy Photo ID:

Upload your Files

Front Copy Insurance Cards:

Upload your Files

Back Copy Insurance Cards:

Upload your Files

Download File file 2

Patient Information

Patient Name (Complete name):

Nickname/Preferred Name:

Birth Date:

SS#:

Sex:
MF

Street Address:

City:

State:

Zip Code:

P.O. Box:

Primary Phone:

Secondary Phone:

Email Address:

Work Phone:

Occupation:

Employer:

Spouse/Partner Name or Parent Name For Minor Patients (If applicable)

Name (Complete):

Relationship:

Primary Phone:

Secondary Phone:

Preferred Pharmacy:

Pharmacy Phone:

Emergency Contact (If different than above)

Name (Complete):

Relationship:

Primary Phone:

City/State:

Primary Insurance Info

Insurance Card Holder’s Name (if different than patient):

Company:

Birth Date:

SS#:

Group#:

Policy:

Secondary Insurance (if applicable)

Company:

Group:

SS#:

Policy:

Primary Phone:

Secondary Phone:

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Synergy Mental Health and Wellness Integrated or insurance company to release any information required to process my claims.

Patient/Guardian Signature:

Parient Date:

Referral Source / Mental health history: please give a brief description of concerns/previous diagnosis:

[cf7mls_step cf7mls_step-1 "Next" ""]

Consent For Telehealth Services

What are Telehealth Services? Telehealth services are used when our patients and their respective physicians, psychiatrists or other clinical personnel (hereafter "Clinicians”) cannot be physically together for mental health evaluation needs or the provision of individualized or grouplevel services. Telehealth services use video and audio technology to send both voice and visual images between you and the Clinicians.

How do Telehealth Services work? All patients participating in Telehealth delivery should use their reasonable best efforts to interface with Clinicians in a private setting using a two-way, interactive device with video capability (e.g. personal computers, tablets, smartphones or other personal devices with video capability). Treating Clinicians interfacing with patients will also utilize similar equipment in private settings when delivering care. Patients participating in group-level services should use their reasonable best efforts to maintain patient privacy for all participating patients and should ensure third parties are not able to overhear or view participating patient information

Are Telehealth Services private and secure? The interactive electronic systems used comply with federal privacy and security law and/or as otherwise directed by Health and Human Services, Office of Civil Rights and other Federal oversight agencies.

However, when it comes to privacy and security with group-level services, it is the responsibility of each participating patient to ensure that while participating in the telepsychiatry services they ensure that no third parties are present or listening to the group-level session.

What happens if I choose not to consent to Telehealth Services? If you choose not to consent to Telehealth services, you will be provided with an onsite Clinician to provide you face-to face psychiatric services, subject to the Facility's capability to provide onsite psychiatric services.Telemedicine privileges shall include consulting, prescribing, rendering a diagnosis or otherwise providing clinical treatment to patients through the use of visual & audio technology.

My Rights and Responsibilities

I understand that the laws that protect the privacy and confidentiality of medical information also apply to telehealth services. yes

I understand that the technology used is encrypted to prevent unauthorized access to my private medical information or is otherwise consistent with guidance from Health and Human Services, Office of Civil Rights and other Federal oversight agencies. yes

I understand that in some circumstances I may only be able to provide my verbal consent to the terms of this Consent and that verbal consent shall be documented by the Clinicians and/or the facility and shall be of the same force and effect as my written consent. yes

I have the right to withhold or withdraw my consent to the use of telehealth services during the course of my care at any time. I understand that my withdrawal of consent will not affect my eligibility to receive future care or treatment. I further understand that declining telehealth services may result in delays or restrictions in accessing on-site care subject to facility capabilities. yes

I understand that the Clinicians and/or facility have the right to withhold or withdraw this consent for the use of telehealth services during the course of my care at any time if it is determined I am not able to reasonably participate in telehealth delivery. yes

I understand that in the event I do not make my reasonable best efforts to ensure the privacy of other participating patients in group-level services, the Clinicians and/or facility have the right to withhold or withdraw the availability of Telehealth services to me. yes

I understand that all rules and regulations which apply to the practice of medicine in the state of Arizona also apply to telehealth services. yes

I understand I may not have any face to face contact with my Clinicians, except for my telehealth services visits. yes

Telehealth services will not be recorded. yes

The Clinicians will inform me if any other person can hear or see any part of our telehealth services session before the session begins yes

Patient Consent To The Use of Telehealth Services

I consent to telehealth services and I have read and understand the information provided above regarding telehealth services. I have had the opportunity to ask questions about this information and questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth services in my psychiatric care and authorize use of telemedicine in the course of my diagnosis and treatment. yes

Name:

Signature:

Date:

[cf7mls_step cf7mls_step-2 "Back" "Next" "Step 2"]

Medication Consent

My physician will discuss:

1. The nature of my mental condition that may include the following: (please check each one you feel represents a concern of yours):

2.The reasons that my physician has for prescribing the medication, including the likelihood of my condition improving or not improving without the medicine. You should start to notice some benefits of this medication within 1 to 2 weeks after initiation of therapy. If you have experienced no benefit after one month of treatment at the prescribed dose, contact your doctor. Maximum benefits usually seen after 6 weeks or more. This medicine must be taken for several weeks before its full benefits are felt. Do not stop taking the medication suddenly because you may experience dizziness, headache, nausea, sweating, increased heart rate or anxiety. If you are pregnant or planning to become pregnant contact your prescriber immediately

3. Reasonable alternative treatments available for my condition, including, but not limited to exercise (as allowed by your primary physician) and diet.

4. The type of medication that I will be receiving, the frequency and range of dosages, the method by which I will take the medication, and duration of such treatment. The side effects of these drugs, known to commonly occur, and any side effects likely to occur in my case

Nausea, vomiting, diarrhea: Take with food. Consult with prescriber if it becomes bothersome
Dry mouth:Suck on sugarless gum or candy. Call your prescriber if your mouth feels dry for more than 2 weeks.
Constipation:Drink plenty of water and increase fiber in your diet.
Sleepiness:May want to take medication at bedtime Decreased appetite Consult with your prescriber Fatigue - Try regular exercise
Sexual dysfunction:Reversible, consult your prescriber.
Sweating:Consult your prescriber
Dizziness:Get up slowly. Do not drive or operate machinery until you know how this medication affects you.
Headache:Talk to your prescriber
Flu-like symptoms:Report to prescriber if symptoms persist for longer than one week.
Weight gain:Increase your physical activities. Avoid foods high in fat and sugar. Consult your prescriber if you have excessive weight gain.
Increased:blood sugar or cholesterol Have your blood tested regularly (every 3-6 months) by your prescriber, especially if you have diabetes or heart problems

[cf7mls_step cf7mls_step-3 "Back" "Next" "Step 3"]

Medication Consent

Rare side effects may occur, in which situation you should call your prescriber immediately or go to the nearest emergency department - Extreme restlessness, suicidal thoughts, hallucinations, rash, muscle pain, fevers or chills, skin yellowing, increased breast size or milk production, edema, low blood pressure, bleeding, seizures, abnormal muscle or joint movements, difficulty speaking, swallowing or breathing, tremor or hair loss

I was given specific information about the recommended medication. I understand that this is only a partial listing of information, and I should discuss all my medical problems and any medication that I take with my physician(s) and my pharmacist(s). Prescribed agents may include the following: Antianxiety Agents (Xanax, Klonopin, Ativan…) Antidepressants (Zoloft, Paxil, Celexa, Lexapro, Wellbutrin, Cymbalta, Effexor…) Antipsychotics (Haldol, Zyprexa, Geodon, Risperdal, Seroquel…) Mood Stabilizer (Depakote, Lithium, Tegretol, Trileptal, Neurontin…) Psychostimulants (Adderall, Vyvanse, Concerta, Strattera, Ritalin…) Sedative/hypnotics (Vistaril, Trazodone, Remeron, Lunesta, Ambien…) And other psychoactive medications

Printed Patient Name:

Signature of Patient or Guardian:

Date:

[cf7mls_step cf7mls_step-4 "Back" "Next" "Step 4"]

Medication History Form

SNRI’s:
Desvenlafaxine (Pristiq)Duloxetine (Cymbalta)Levomilnacipran (Fetzima)Venlafaxine (Effexor)

Dopamine Reuptake Inhibitor:
Bupropion (Wellbutrin)

S-HT1 Receptor Antagonist:
(Vistaril) Vilazodone (Viibyrd)

S-HT2 Receptor Antagonist:
TrazodoneNefazodone

S-HT3 Receptor Antagonist:
(Brintellix)

Noradrenergic Antagonist:
Mirtazapine (Remeron)

Combo Meds:
Olanzapine/fluoxetine (Symbyax)

Herbs/Supplements:
St. John's WortSAMe (S-Adenosylmethionine)

TCA’s:
AmitriptylineNortriptylineDoxepin

MAOI’s:
Isocarboxazid (Marplan)Phenelzine (Nardil)Selegiline (Emsam) and Tranylcypromine (Parnate)

Off Label Mood Stabilizers:
OxcarbazepineTopiramateGabapentin

Typical Antipsychotics:
Haloperidol (Haldol)Fluphenazine (Prolixin)Perphenazine (Trilafon)Thioridazine (Melleril or Mellaril)Thiothixene (Navane)

[cf7mls_step cf7mls_step-5 "Back" "Next" "Step 5"]

Privacy Policy

This explains HIPAA laws and when and how our office can release information about you. Protected health information includes descriptive information that can be used to identify a person and that relates to the treatment for a mental health condition. The protected health information includes information from the past, present, or future. The right to privacy continues after death. Synergy Mental Health and Wellness Integrated does not release health information about people who receive services from our office.

This means our office cannot release:

Information that will tell people who you are or where you live
Information about your mental health or condition
Information about any of the services you are receiving
Information about how your services are paid for

If you choose to sign a consent form for a person or facility; our office can release the requested information to only that person or facility. Our office is not required to release copies of records to individuals. The release of records to individuals is determined by the clinician.
There are some special circumstances when our office is required to release information about you, even if you have not given us permission to do so.

For example:

If you are sick or hurt
If you are not safe to take care of yourself
If you try to hurt someone or someone is trying to hurt you
If you tell us about child abuse
Under a court order

By signing this form, you are stating that you have read and understand the terms stated within and have received
a copy of the Notice of Privacy Practices.

Printed Patient Name:

Signature of Patient or Guardian:

Date:

[cf7mls_step cf7mls_step-6 "Back" "Next" "Step 6"]

Release Of Information Form

Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

1. Authorization

a. I authorize:

to use and disclose the protected health information described below to SMHWI (individual seeking the information).

2. Effective Period

a. This authorization for release of information covers the period of healthcare from:
all past, present, and future periodsOr other

If check other specific:

To:

3. Extent of Authorization

authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).

Initial:

Or:

authorize the release of my complete health record with the exception of the following information:

Mental health recordsCommunicable diseases (including HIV and AIDS)Alcohol/drug abuse treatment (Per CFR 42.2)

Other (please specify)

Initial

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

Date or event

(date or event), 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.

Printed Patient Name:

Signature of Patient or Guardian:

Date

[cf7mls_step cf7mls_step-7 "Back" "Next" "Step 7"]

Consent For Treatment

TO THE PATIENT: text duplicated You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended.

This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing.

You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Printed Patient Name:

Signature of Patient or Guardian:

Date:

[cf7mls_step cf7mls_step-8 "Back" "Next" "Step 8"]

Patient Contract

Please read and sign below acknowledging that you have read, understand, and agree to the terms in this contract.

OFFICE HOURS: Our office hours are Monday to Friday 8:00 am– 5:00 p.m.

APPOINTMENTS: Co-payment, co-insurances, and/or deductibles are due at the time of service and any balances must be paid before future appointments can be scheduled.

FEES NOT COVERED BY INSURANCE: Fees for the items listed below are not covered by insurance companies and are the patient’s responsibility. Fees for these items must be paid at the time the service is rendered and prior to the next scheduled appointment

Fees for no shows or cancellations less than 24 hours before the appointment
$100 No show or late cancellation fee (99999)
Fees for medical records sent to attorneys or other agencies (waived if sent directly to another provider, hospital, or insurance company)
$50 Letter preparation fee (90889) - $1 per page fee for each page
Fees for returned checks
Fees for disability forms, FMLA forms, or letter preparation
$25 per five minutes phone consultation fee, billed in 5-minute for patients who choose to contact a provider after hours for a non-emergency, will be billed for a phone consultation

FEES FOR CASH PAY PATIENTS: This is not a comprehensive list of all fees in this office; please inquire about current fees prior to authorizing any service that is not covered by your insurance company.

$400 for initial psychiatric evaluation (99205)
$200 Moderate Complexity Medication Management (99214)
$50 Urine Drug Screen (80305)
$100 Psychotherapy add-on (90833)
$200 for Initial New Therapy (90791)
$120 for Established Therapy (90837)
$100 Group therapy (90853)
$100 Disability and/or FMLA Form preparation (up to 5 pages) (90889)
$25 per five minutes phone consultation fee, billed in 5-minute increments (99441-3)

INSURANCE & PATIENT RESPONSIBILITY: It is the patient’s responsibility to notify us with any insurance changes and to obtain any required authorizations. Our office will submit claims to the insurance company we have on file. Per our contractual obligation with insurance companies, we must collect all co- payments and/or deductibles due from the patient at the time of service unless other arrangements have been made in advance. Should the insurance company not cover the service, the balance may become payable by you. Any balance due from the client that is not paid within 90 days will be referred to a collection agency.

You agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collection effort.

PRESCRIPTION REFILLS: All prescription refills are handled during appointments exclusively, if you need a refill and do not have an appointment, please contact your pharmacy and they will contact us. WE DO NOT FILL EMAIL OR TELEPHONE REQUESTS MADE BY THE PATIENT NOT FROM THE PHARMACY.

RELEASE OF RECORDS: All patients or their parent/legal guardian must sign a release authorizing the release of any information. No information will be released without a properly executed consent. Record requests may take up to 30 days to process and payment is required.

REASONS FOR TERMINATION: The reasons listed below are common reasons for termination from our office. This list is not comprehensive, and the treating provider has final authority on terminating treatment.

Continuously canceling or not showing for scheduled appointments
Not following the recommended treatment plan
If the patient is not seen within 6 months, unless otherwise instructed by your provider, your file will be closed (voluntarily terminated) and no prescriptions will be authorized for refills until you are seen.

EMERGENCY CONTACT NUMBERS: We are an out-patient practice. The emergency phone numbers provided on the office voicemail are for after-hour urgent issues that are not life threatening. If you are experiencing a lifethreatening emergency such as violent or suicidal thoughts, you must call 911 immediately.

CONFIDENTIALITY: In accordance with moral, ethical, and legal guidelines regarding your right to confidentiality, a patient's personal information is carefully guarded. However, there are some exceptions which must be noted:

If a patient poses a threat to his or her own safety or the safety of others, we are required to notify concerned parties and the authorities.
If a patient reports actual or suspected abuse of any individual, our office must notify the proper authorities.
In patient groups of two or more, including the lobby and check-out, confidentiality is urged but not guaranteed.

CREDIT CARD AUTHORIZATION: I allow SMHWI to automatically charge my credit card for any outstanding balances. These may include; insurance denials for ANY reason, missed or canceled appointments, deductibles, coinsurances, partially paid claims.

Missed or canceled appointments without 24-hour notice will be charged $100.00.

AUTHORIZATION & SIGNATURE ON FILE: By signing this form, I authorize Synergy Mental Health and Wellness Integrated to release all necessary information to insurance companies to process claims or obtain authorization for treatment. I authorize payments to be made to {Enter Provider Name} from insurance companies, government agencies, or any other agency providing benefits for services rendered. I authorize that a copy of the signature below may substitute as the original.

I have read, understood, and agree to follow all terms and conditions of this contract.

Printed Patient Name:

Signature of Patient or Guardian:

[cf7mls_step cf7mls_step-9 "Back" "Next" "Step 9"]

Credit Card Authorization Form

Thank you for choosing Synergy Mental Health and Wellness Integrated (SMHWI) for your mental health needs.
We are committed to providing you with exceptional care, as well as making our insurance billing processes as simple and efficient as possible. Recent shifts in the healthcare industry have resulted in insurance companies increasingly transferring costs to our patients, you, the insured. This is driving many practices to adopt new financial policies to enable more efficient operational processes. Some insurance plans require deductibles and copayments in amounts not known to you or us at the time of your visit

To streamline our billing and payment system and to provide a seamless, convenient way for patients to pay their bills, SMHWI will require all patients keep an active credit card on file with us. We will bill your insurance company first and upon their determination of benefits, we will only charge your credit card when they inform us of patient responsibility. Circumstances when your card would be charged include but are not limited to: missed or canceled sessions without 24-hour notice ($100), missed co- payments, deductible and coinsurance, any noncovered services and/or denial of services, including the first/psychiatric assessment appointment.

Once your insurance has processed your claims, they will send an Explanation of Benefits (EOB) to both you and our office showing the amount of your total patient responsibility. You will typically receive the EOB before we do, so if you disagree with the patient responsibility balance owed, it is your responsibility to contact your insurance carrier immediately.
When we receive the EOB, we will enter all pertinent payment information into our system. At that time, any remaining balance owed by you will be charged to your credit card and a copy of the charge will be sent to you.

If the credit card we have on file for you changes, please notify your clinicians IMMEDIATELY by phone or email. It is not uncommon for people to change or cancel their credit cards for various reasons, including when a credit card expires. If we run your credit card and it is denied for any reason, we reserve the right to charge an additional $25 declined card fee if we are not able to run a new credit card within 7 days.

We will contact you or leave you a phone message on the phone number you provided for us, asking you to give us a call with the new number right away. We will enter the new credit card number into your file, and that will become your new card on-file, subject to the same financial policy as the card you gave us in-person when you were in our office.

If there is a problem with your bill/claim and it is brought to our attention after your credit card payment processes,
we will investigate it and if we owe you the money, we will refund it to the same card in a timely manner. We understand that there are legitimate reasons that you may not have a credit card. If this is the case, you are welcome to leave an HSA (Health Savings Account) or Flex Plan Card on File. You may also pay for the visit with cash or a personal check.

By signing below, I agree to the SMHWI Credit Card on File Policy and I authorize SMHWI to keep my signature and a valid credit/debit card number securely on-file in my account. I allow SMHWI to automatically charge my credit card for any outstanding balances. These may include; insurance denials for ANY reason (including no referral on file), deductibles, coinsurances, partially paid claims, and missed or canceled appointments without 24-hour notice will be charged the full $100.00 fee.

If the credit card that I give today changes, expires, or is denied for any reason, then I agree to immediately give SMHWI a new, valid credit card which I will allow them to key-in over the phone. Even though SMHWI is not swiping this card in person, I agree that the new card will still be subject to the financial policy listed here and may be used with the same authorization as the original card which I presented in person.

I understand that I am responsible for payment for all medical services provided to me by SMHWI. I understand that my insurance may deny or delay payment for these services or only partially pay them, and I agree to allow SMHWI to immediately charge my credit card on file for the balance if that happens. I understand that this form is valid until I cancel this authorization through written notice to SMHWI.

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us this authorization will remain in effect until canceled.

Credit Card Information:

Card Type:
MastercardVISADiscoverAmerican Express

Cardholder Name (as shown on card):

Card Number:

Expiration Date (mm/yy):

CVV2:

Cardholder ZIP Code (from credit card billing address):

I,

authorize SMHWI to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

Printed Patient Name:

Signature of Patient or Guardian:

Date:

[cf7mls_step cf7mls_step-10 "Back" "Next" "Step 10"]

No Show/ Late Fee Contract

Thank you for trusting your medical care to Synergy Mental Health and Wellness Integrated. When you schedule an appointment with SMHWI we set aside enough time to provide you with the highest quality care. Should you need to cancel or reschedule an appointment please contact our office as soon as possible, and no later than 48 hours prior to your scheduled appointment.

This gives us time to schedule other patients who may be waiting for an appointment. This policy will be strictly enforced. This policy is non-negotiable. Please see our Appointment Cancellation/No Show Policy below:

***Please initial by each statement***

Phone reminders are a courtesy only. It is a patient responsibility to remember the date and appointment time:

Any cancellation with less than 48 hours’ notice will be considered a late cancellation. There will be no disputes about what constitutes a “valid” reason for canceling. The time will be measured to the minute (i.e. 47 hours, 59 minutes is less than 48 hours):

There will be a $100.00 charge for all no shows and late cancellations:

The second no show or late cancellation will be charged the full fee:

The third no show or late cancellation will be charged the full fee and will result in discharge from the practice:

Fees will be automatically charged to credit/debit cards if this has text duplicated been your form of payment in the past. Patients that pay cash or by check must arrange for payments to be made before an appointment will be rescheduled :

Any new patient who fails to show for their initial visit will not be rescheduled.

Patients who are transferred out of the practice (or who do not agree with this policy) will receive an official letter documenting termination of the physician/patient relationship, a list of other area psychiatrists, and possibly prescriptions for up to 3 months of the last medication regimen prescribed depending on the circumstances of the situation. This will be mailed via certified mail with a return receipt (i.e. must be signed for) to the address on file (so please inform me of any changes in address).

My signature below affirms that I agree to all terms of this policy.

Printed Patient Name:

Signature of Patient or Guardian:

Date:

[cf7mls_step cf7mls_step-11 "Back" "Next" "Step 11"]

Non-insurance Fee Schedule

The fees outlined below are effective 01/01/2020 and may be changed at any time.

This is not a comprehensive list of all fees in this office; please inquire about current fees prior to authorizing any service that is not covered by your insurance company.

$400 for initial psychiatric evaluation (99205)
$200 Moderate Complexity Medication Management (99214)
$30 Urine Drug Screen (80305)
$100 Psychotherapy add-on (90833)
$100 Group therapy (90853)
$100 No show or late cancellation fee (99999)
$50 Letter preparation fee (90889) with $1 fee for each page for records (waived if sent directly to another provider, hospital, or insurance company)
$100 Disability and/or FMLA Form preparation (up to 5 pages) (90889)
$25 per five minutes phone consultation fee, billed in 5-minute increments (99441-3)
$150 for Emotional Support Animal documentation (C9995)

Requires two attended sessions before the letter is written and two additional sessions within the year to renew the letter.

I have read, understood, and agree to the above fees.

Printed Patient Name:

Signature of Patient or Guardian:

Date:

[cf7mls_step cf7mls_step-12 "Back" "Next" "Step 12"]

A. Notifier: Synergy Mental Health and Wellness Integrated. 8350 E. Raintree Dr. Suite 130 Scottsdale, AZ 85260

B. Patient Name:

C. Insurance:

Advance Beneficiary Notice of Non- Coverage (ABN)

Note: If insurance doesn’t pay for D. _ Service_ below, you may have patient responsibility. Insurance does not pay for everything. Even some care that you or your healthcare provider have good reason to think you need. We expect insurance may not pay for the D._Service_ Below

D.

E. Reason insurance may not pay:

Service:

F . Estimated Cost:

Service:

Psychiatry- $400/$200 Therapy- $200/$120:

What you need to know

Read this notice, so you can make an informed decision about your care. Ask us any question you may have after you finish reading or reach out to your insurance company.

Choose an option below about whether to receive a Service

G. Options: Check only one box. We cannot choose a box for you.

Option 1. I want the Services above. I understand that if my insurance doesn’t pay, I am responsible for payment to SMHWI.Option 2. I want the service listed above, but do not bill my insurance. You may ask to be paid now as I am responsible for payment at time of service.Option 3. I don’t want the Service listed above

H. Additional information

I. Signature:

J. Date

[cf7mls_step cf7mls_step-13 "Back" "Next" "Step 13"]

R9-10-1008. Patient Rights

A. An administrator shall ensure that:

The requirements in subsection (B) and the patient rights in subsection (C) are conspicuously posted on the premises.
At the time of admission, a patient or the patient's representative receives a written copy of the requirements in subsection (B) and the patient rights in subsection (C)
Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that include: How and when a patient or the patient's representative is informed of the patient rights in subsection (C), and where patient rights are posted as required in subsection (A)(1).

B. An administrator shall ensure that:

A patient is treated with dignity, respect, and consideration
A patient is not subjected to:
Abuse
Neglect
Exploitation
Coercion
Manipulation
Sexual abuse
Sexual assault
Except as allowed in R9-10-1012(B), restraint or seclusion
Retaliation for submitting a complaint to the Department or another entity
Misappropriation of personal and private property by an outpatient treatment center's personnel members, employee, volunteer, or student

3. A patient or the patient’s representative:

Except in an emergency, either consents to or refuses treatment
May refuse or withdraw consent for treatment before treatment is initiated
Except in an emergency, is informed of alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure.
Is informed of the following:
The outpatient treatment center's policy on health care directives, and
The patient complaint process
and Consents to photographs of the patient before a patient is photographed, except that a patient may be photographed when admitted to an outpatient treatment center for identification and administrative purposes; and
Except as otherwise permitted by law, provides written consent to the release of information in the patient's
Medical record, or
Financial records.

C. A patient has the following rights

Not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, or diagnosis.
To receive treatment that supports and respects the patient's individuality, choices, strengths, and abilities
To receive privacy in treatment and care for personal needs
To review, upon written request, the patient's own medical record according to AR.S. 12-2293, 12-2294, and 12-2294.01;
To receive a referral to another health care institution if the outpatient treatment center is not authorized or not able to provide physical health services or behavioral health services needed by the patient
To participate or have the patient's representative participate in the text duplicated development of, or decisions concerning, treatment
To participate or refuse to participate in research or experimental treatment, and
To receive assistance from a family member, the patient's representative, or other individual in understanding, protecting, or exercising the patient's rights.

Name:

Signature:

Date:

[cf7mls_step cf7mls_step-14 "Back" "Next" "Step 14"]

Your Rights Pursuant to Arizona Administrative Code, Title 9, Chapter 10, Article 9 (Outpatient Surgical Center R9-10- 909) and Article 10 (Outpatient Treatment Centers R9-10-1008)

A patient is treated with dignity, respect and consideration

A patient is not subjected to

Abuse; neglect; exploitation; coercion; manipulation; sexual abuse or assault
Restraint or seclusion, except as allowed in R9-10-1012(B) if the center is authorized to provide behavioral health observation/stabilization services;
Retaliation for submitting a complaint to the Arizona Department of Health Services or another entity; or
Misappropriation of personal and private property by the center's personnel members, employees,
volunteers or students; and

A patient or the patient's representative has the right to: Consent to or refuse treatment, except in an emergency; Refuse or withdraw consent for treatment before treatment is initiated; Be informed of

Except in an emergency, alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure
Policies and procedures on health care directives; and
The patient complaint process

Consent to photographs of the patient before the patient is photographed, except that a patient may be photographed when admitted to the center for identification and administrative purposes; and Except as otherwise permitted by law, provide written consent to the release of information in the patient's medical record or financial records.

A patient has the following rights:

Not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status or diagnosis
To receive treatment that supports and respects the patient's individuality, choices, strengths and abilities
To receive privacy in treatment and care for personal needs
To review, upon written request, the patient's own medical record according to ARS 12-2293, 12-2294 and 12- 2994.01
To receive a referral to another health care institution if the center is not authorized or not able to provide physical health services or behavioral health services needed by the patient
To participate or have the patient's representative participate in the development of, or decisions concerning, treatment
To participate or refuse to participate in research or experimental treatment; and
To receive assistance from a family member, representative or other individual in understanding, protecting or exercising the patient's rights.

Name:

Signature:

Date:

[cf7mls_step cf7mls_step-15 "Back" "Next" "Step 15"]

Advance Directives Acknowledgment

Medical/Healthcare Advance Directives:
I HAVE NOT executed an Advance DirectiveI HAVE executed an Advance DirectiveI HAVE NOT provided the facility with a copy of the Advance DirectiveI HAVE provided the facility with a copy of the Advance Directive

Mental Health Advance Directives:
I HAVE NOT executed an Advance DirectiveI HAVE executed an Advance DirectiveI HAVE NOT provided the facility with a copy of the Advance DirectiveI HAVE provided the facility with a copy of the Advance Directive

I acknowledge the following:

I have been informed of my rights to formulate Advance Directives
I understand that I am not required to have Advance Directives in order to receive treatment at this facility.
I understand the terms of any Advance Directive I have executed will be followed by the facility and my caregivers to the extent permitted by law.
Under NO circumstances will a DO NOT RESUSCITATE order be honored at Synergy Mental Health and Wellness Integrated. All patients who are or become non-responsive will be resuscitated within the facilities capabilities and transferred to the closest medical facility.

For more information and forms on Advance Directives you can contact the Office of the Arizona Attorney General.

Office of Arizona Attorney General

Life Care Planning Information and Documents Direct Line: 602-542-2123

Toll Free: 800-352-8431

Fax: 602-364-1970

Print Name:

Patient Signature:

Legal Guardian:

Legal Guardian Name/POA:

Documentation

Upload front and back of insurance card, ID/Driver's License, and custody documentation if applicableduplicate 8
**(Patients using insurance for appointments will have to provide a copy of the front and back of insurance card prior to scheduling)duplicate 8**

Please select the documents you wish to send
IDDriver's LicenseInsurance Cards

Please, ensure that the files that you are attaching for submission do not exceed the maximum size of 10 MB. Files larger than this might cause that your files do not get to our offices along with your information.
If you do not have this any of these files in digital, you can bring them to your first consultation with our doctors.

Front Copy DL:

Upload your Files

Back Copy DL:

Upload your Files

Front Copy Photo ID:

Upload your Files

Back Copy Photo ID:

Upload your Files

Front Copy Insurance Cards:

Upload your Files

Back Copy Insurance Cards:

Upload your Files

[cf7mls_step cf7mls_step-16 "Back" "Step 16"]

It is important that our patients provide us with the information requested for these forms Financial Policy and Fillable Nutritional Screening in order to complete the process.

Download File

Family Behavioral Health

Child And Adolescent Psychiatric History

Demographic Data

Name Contact:

Email Contact:

Form filled out by

Relationship to patient

Patient Name

DOB

Date

Patient’s Age

SEX
MF

Race

Child’s legal guardian

Please give a brief description of the problem(s) your child is having:

How long has the problem been going on?

On a scale of 1-10, how would you rate the severity of your child’s problem(s) during the past month?

Past Psychiatric History

Has your child ever had any form of mental health treatment in the past?
YesNo

If yes, please describe the type of treatment, the approximate dates and the name of the provider, agency, or hospital

Has the patient ever made any sucicide attempts?
YesNo

If yes, please fill out the fields.

Date of Attempt

Method Used

Treatment Received (if any)

Has the patient engaged in self mutilation such as cutting, biting, scratching, or burning?
YesNo

Type of self mutilation:

Frequency

[cf7mls_step cf7mls_step-1 "Next" "Step 2"]

Has the patient taken any psychiatric meds in the past?
YesNo

If yes, please fill out the fields

Medication

Dates Medication

Duration Medication

Dosage Medication

Benefits Medication

Side effects Medication

Medical History

Has the patient had a physical exam in the past year?
YesNo

Findings:

Current Medications - Please include medical, psychiatric, over the counter drugs, as well as herbal or
nutritional supplements

Medication

Dose

Instructions

Effectiveness

Benefits

Have there been any recent medication changes?
YesNo

Findings:

Medication Allergies:
YesNo

Name of drug followed by reaction:

Current Medical Problems:
YesNo

Past Medical/Surgical History:

[cf7mls_step cf7mls_step-2 "Back" "Next" "Step 3"]

Medical History Questions:

Does the child have vision problems?
YesNo

Effectiveness:

Does the child have hearing problems?
YesNo

Effectiveness:

Has the child ever had a seizure?
YesNo

Effectiveness:

Has the child ever had a head injury?
YesNo

Effectiveness:

Did the head injury result in loss of consciousness?
YesNo

Effectiveness:

Did the child receive treatment for the head injury?
YesNo

Effectiveness:

[cf7mls_step cf7mls_step-3 "Back" "Next" "Step 4"]

Has the patient ever had any of the following tests?

MRI or CAT scan of the head
YesNo

Date

Results

EEG (a test for seizures)
YesNo

Date

Results

EKG (a test for seizures)
YesNo

Date

Results

Family Medical History

Please check any of the following conditions that have affected an immediate or extended family member related by blood. Indicate maternal (mother) or paternal (father) side.

Autoimmune disorder
YesNo

Family member

Mat/Pat

Blood disorders
YesNo

Family member

Mat/Pat

Cancer
YesNo

Family member

Mat/Pat

Diabetes
YesNo

Family member

Mat/Pat

Heart disease
YesNo

Family member

Mat/Pat

Hepatitis
YesNo

Family member

Mat/Pat

High blood pressure
YesNo

Family member

Mat/Pat

Kidney disease
YesNo

Family member

Mat/Pat

Leukemia
YesNo

Family member

Mat/Pat

Live disease
YesNo

Family member

Mat/Pat

Migraines
YesNo

Family member

Mat/Pat

Muscle Disorder
YesNo

Family member

Mat/Pat

Obesity
YesNo

Family member

Mat/Pat

Seizures
YesNo

Family member

Mat/Pat

stroke
YesNo

Family member

Mat/Pat

T.B.
YesNo

Family member

Mat/Pat

Thyroid disease
YesNo

Family member

Mat/Pat

Other
YesNo

Family member

Mat/Pat

[cf7mls_step cf7mls_step-4 "Back" "Next" "Step 5"]

Family Psychiatric History

Please check any of the following conditions that have affected an immediate or extended family member related by blood. Indicate maternal (mother) or paternal (father) side.

Alcoholism
YesNo

Family member

Mat/Pat

Anxiety problems
YesNo

Family member

Mat/Pat

Arrests
YesNo

Family member

Mat/Pat

Autism
YesNo

Family member

Mat/Pat

Attention problems
YesNo

Family member

Mat/Pat

Bipolar disorder
YesNo

Family member

Mat/Pat

Depression
YesNo

Family member

Mat/Pat

Dropped out of school
YesNo

Family member

Mat/Pat

Eating disorder
YesNo

Family member

Mat/Pat

Hallucinations
YesNo

Family member

Mat/Pat

Hyperactivity
YesNo

Family member

Mat/Pat

Learning disability
YesNo

Family member

Mat/Pat

Mental retardation
YesNo

Family member

Mat/Pat

Mood swings
YesNo

Family member

Mat/Pat

Schizophrenia
YesNo

Family member

Mat/Pat

Substance abuse
YesNo

Family member

Mat/Pat

Tics or tourette’s
YesNo

Family member

Mat/Pat

Violence
YesNo

Family member

Mat/Pat

Suicide attempts
YesNo

Family member

Mat/Pat

Other
YesNo

Family member

Mat/Pat

[cf7mls_step cf7mls_step-5 "Back" "Next" "Step 6"]

Social History

How does the child get along with:

Peers?

Parents?

Teachers?

Siblings?

Father’s occupation:

Mother’s occupation:

Is the child adopted?
YesNo

If yes, how old was the child when he/she came to live with you?

Does the child know he/she is adopted?
YesNo

Are the child’s parents divorced?

If yes, what are the custody visitation arrangements?

Please list all persons who currently live in the child’s household:

Input Name - Relationship - Age per line

List any immediate family members not living with the child (i.e. mother, father, or siblings):

Input Name - Relationship - Age per line

Has the child ever experienced or been exposed to any of the following?

Physical abuse
YesNo

Explanation

Sexual abuse
YesNo

Explanation

Emotional abuse
YesNo

Explanation

Neglect
YesNo

Explanation

Domestic violence
YesNo

Explanation

[cf7mls_step cf7mls_step-6 "Back" "Next" "Step 7"]

Developmental History

Mother’s age when child was born

Father’s age when child was born

Child’s birth weight

Apgar scores (if known)

Type of delivery
VaginalInducedScheduled C-sectionEmergency C-section

Questions

Was the pregnancy planned?
YesNo

Explanation

Were there problems during the pregnancy?
YesNo

Explanation

Did the mother receive regular prenatal care?
YesNo

Explanation

Did the mother take medication during pregnancy?
YesNo

Explanation

Did the mother drink alcohol during the pregnancy?
YesNo

Explanation

Did the mother take drugs during the pregnancy?
YesNo

Explanation

Did the mother smoke during the pregnancy?
YesNo

Explanation

Were there any problems during the labor?
YesNo

Explanation

Were there any complications during the delivery?
YesNo

Explanation

Were there any problems after the birth?
YesNo

Explanation

Did the mother suffer from postpartum depression?
YesNo

Explanation

Was the child premature or late?
YesNo

Explanation

Did the child have a consistent caretaker?
YesNo

Explanation

[cf7mls_step cf7mls_step-7 "Back" "Next" "Step 8"]

What was the child like as a baby?

Did the child experience delays or impairments in any of the following areas?

Feeding
YesNo

Gross motor skills (running, jumping, skipping)
YesNo

Toilet training
YesNo

Fine motor skills (writing, coloring, cutting)
YesNo

Speech/language
YesNo

Bedwetting after toilet trained mastered
YesNo

Walking
YesNo

Soiling after toilet training mastered
YesNo

Other
YesNo

Explain

[cf7mls_step cf7mls_step-8 "Back" "Next" "Step 9"]

Educational History

Current school

Grade

Type of classroom
mainstreamspecial educationself-containedemotionally disturbed

Does the patient have an Individual Education Plan (IEP) or 504 plan (accommodations)?
YesNo

Has the child had any psychological or educational testing?
YesNo

Where and when was the testing done?

Has the child ever repeated a grade?
YesNo

If yes, which one?

Has the child ever been diagnosed with a learning disability?
YesNo

Explain

Has the child ever been diagnosed with
Mental retardationAutismAspergers

[cf7mls_step cf7mls_step-9 "Back" "Next" "Step 10"]

Substance Abuse History

Has the patient used any of the following substances?
YesNo

Alcohol

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Acid/LSD/PCP

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Crystal Meth/Speed

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Cocaine/Crack

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Ecstasy

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Heroin

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Inhalants

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Marijuana/Pot

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Methadone

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Nicotine

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Opiates/Pain Killers

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Sedatives/Downers

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

Other

Age of 1st Use

Date of Last Use

Amount Consumed

Frequency of Use

Route of Administration

[cf7mls_step cf7mls_step-10 "Back" "Next" "Step 11"]

Legal History

Has the patient ever been arrested, charged or placed on probation or parole?
YesNo

If yes, what were the charges?

Has the child ever been held in Juvenile Detention?
YesNo

If yes, how many times?

Psychatric Symptoms

Please check any of the following symptoms your child has experienced in the past year.

Physical

Problems falling asleep or staying asleep
YesNo

Sleeps a lot
YesNo

Change in appetite
YesNo

increased or decreased
IncreasedDecreased

Change in weight
YesNo

increased or decreased
IncreasedDecreased

Tiredness or fatigue
YesNo

Headaches
YesNo

Stomach pains
YesNo

Joint pain or swelling
YesNo

Agitation or restlessness
YesNo

Poor hygiene
YesNo

Soiling (lack of bowel control)
YesNo

Bedwetting
YesNo

Wetting during the day
YesNo

Chest pain Cognitive
YesNo

Decreased concentration
YesNo

Easily distracted
YesNo

Forgetfulness
YesNo

Confusion or disorientation
YesNo

Unresponsive at times
YesNo

Slowed thinking
YesNo

Shortness in breath
YesNo

Dizziness
YesNo

Heart palpitations or racing heart
YesNo

Feeling faint
YesNo

Fainting spells
YesNo

Psychological

Periods of elevated mood, excessive talking, giddy or silly behavior, uncontrollable laughing
YesNo

Hearing voices
YesNo

Seeing things that aren’t there
YesNo

Fears that someone is trying to hurt him/her
YesNo

Acts paranoid
YesNo

Becomes distressed when away from caregiver
YesNo

Clingy behavior
YesNo

Afraid to be alone
YesNo

Excessive worries
YesNo

Fears
YesNo

Nightmares
YesNo

Obsessive and distressing thoughts
YesNo

Compulsive behaviors or rituals (excessive hand washing, arranging, checking)
YesNo

Repetitive movements (eye blinking, facial/nose twitches, mouth movements)
YesNo

Repetitive sounds (sniffing, snorting, grunting, growling, clearing the throat)
YesNo

[cf7mls_step cf7mls_step-11 "Back" "Next" "Step 12"]

Behavioral

Hyperactivity
YesNo

Impulsivity
YesNo

Oppositional/defiant behavior
YesNo

Argumentative
YesNo

Destructive
YesNo

Anger outbursts
YesNo

Rages that may last up to an hour or more
YesNo

Cruelty to others
YesNo

Cruelty to animals
YesNo

Bullies or teases others
YesNo

Firesetting
YesNo

Has runaway from home
YesNo

Physical aggression
YesNo

Lies
YesNo

Steals
YesNo

Refuses to do chores
YesNo

Demonstrates poor judgment
YesNo

Inappropriate sexual behavior
YesNo

School refusal
YesNo

Withdrawal from family/friends
YesNo

Communication

Difficulty communicating his/her thoughts or wishes to other
YesNo

Difficulty understanding verbal or written language
YesNo

Difficulty speaking words clearly
YesNo

Stutters
YesNo

[cf7mls_step cf7mls_step-12 "Back" "Next" "Step 13"]

Academic

Difficulty reading at grade level
YesNo

Difficulty doing math at grade level
YesNo

Difficulty writing at grade level
YesNo

Mood Disorder Questionnaire

Please answer each question to the best of your ability

<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?
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 so 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 active or did many more things 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 checked YES to more than one of the above, have several of these ever happened during the same period of time?
YesNo

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 Problem
YesNo

Minor Problem
YesNo

Moderate Problem
YesNo

Serious Problem
YesNo

[cf7mls_step cf7mls_step-13 "Back" "Next" "Step 14"]

Beck's Depression Inventory

This depression inventory can be self-scored. The scoring scale is at the end of the questionnaire

1.

0. I do not feel sad
YesNo

1. I feel sad
YesNo

2. I am sad all the time and I can't snap out of it.
YesNo

3. I am so sad and unhappy that I can't stand it.
YesNo

2.

0. I am not particularly discouraged about the future.
YesNo

1. I feel discouraged about the future.
YesNo

2. I feel I have nothing to look forward to.
YesNo

3. I feel the future is hopeless and that things cannot improve.
YesNo

3.

0. I do not feel like a failure
YesNo

1. I feel I have failed more than the average person.
YesNo

2. As I look back on my life, all I can see is a lot of failures.
YesNo

3. I feel I am a complete failure as a person.
YesNo

4.

0. I get as much satisfaction out of things as I used to
YesNo

1. I don't enjoy things the way I used to.
YesNo

2. I don't get real satisfaction out of anything anymore.
YesNo

3. I am dissatisfied or bored with everything
YesNo

5.

0. I don't feel particularly guilty
YesNo

1. I feel guilty a good part of the time
YesNo

2. I feel quite guilty most of the time
YesNo

3. I feel guilty all of the time
YesNo

6.

0. I don't feel I am being punished
YesNo

1. I feel I may be punished.
YesNo

2. I expect to be punished
YesNo

3. I feel I am being punished
YesNo

7.

0. I don't feel disappointed in myself
YesNo

1. I am disappointed in myself.
YesNo

2. I am disgusted with myself.
YesNo

3. I hate myself
YesNo

8.

0. I don't feel I am any worse than anybody else
YesNo

1. I am critical of myself for my weaknesses or mistakes
YesNo

2. I blame myself all the time for my faults
YesNo

3. I blame myself for everything bad that happens
YesNo

9.

0. I don't have any thoughts of killing myself
YesNo

1. I have thoughts of killing myself, but I would not carry them out
YesNo

2. I would like to kill myself
YesNo

3. I would kill myself if I had the chance
YesNo

10.

0. I don't cry any more than usual
YesNo

1. I cry more now than I used to
YesNo

2. I cry all the time now
YesNo

3. I used to be able to cry, but now I can't cry even though I want to
YesNo

11.

0. I am no more irritated by things than I ever was
YesNo

1. I am slightly more irritated now than usual
YesNo

2. I am quite annoyed or irritated a good deal of the time.
YesNo

3. I feel irritated all the time
YesNo

12.

0. I have not lost interest in other people
YesNo

1. I am less interested in other people than I used to be
YesNo

2. I have lost most of my interest in other people
YesNo

3. I have lost all of my interest in other people
YesNo

13.

0. I make decisions about as well as I ever could
YesNo

1. I put off making decisions more than I used to
YesNo

2. I have greater difficulty in making decisions than I used to
YesNo

3. I can't make decisions at all anymore
YesNo

14.

0. I don't feel that I look any worse than I used to
YesNo

1. I am worried that I am looking old or unattractive
YesNo

2. I feel there are permanent changes in my appearance that make me look unattractive
YesNo

3. I believe that I look ugly
YesNo

15.

0. I can work about as well as before
YesNo

1. It takes an extra effort to get started at doing something
YesNo

2. I have to push myself very hard to do anything
YesNo

3. I can't do any work at all.
YesNo

16.

0. I can sleep as well as usual.
YesNo

1. I don't sleep as well as I used to.
YesNo

2. I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
YesNo

3. I wake up several hours earlier than I used to and cannot get back to sleep.
YesNo

17.

0. I don't get more tired than usual
YesNo

1. I get tired more easily than I used to
YesNo

2. I get tired from doing almost anything
YesNo

3. I am too tired to do anything
YesNo

18.

0. My appetite is no worse than usual
YesNo

1. My appetite is not as good as it used to be
YesNo

2. My appetite is much worse now
YesNo

3. I have no appetite at all anymore
YesNo

19.

0. I haven't lost much weight, if any, lately
YesNo

1. I have lost more than five pounds
YesNo

2. I have lost more than ten pounds
YesNo

3. I have lost more than fifteen pounds.
YesNo

20.

0. I am no more worried about my health than usual
YesNo

1. I am worried about physical problems like aches, pains, upset stomach, or constipation
YesNo

2. I am very worried about physical problems and it's hard to think of much else
YesNo

3. I am so worried about my physical problems that I cannot think of anything else
YesNo

21.

0. I have not noticed any recent change in my interest in sex
YesNo

1. I am less interested in sex than I used to be
YesNo

2. I have almost no interest in sex
YesNo

3. I have lost interest in sex completely
YesNo

Interpreting The Beck Depression Inventory

Now that you have completed the questionnaire, add up the score for each of the twenty-one questions by counting the number to the right of each question you marked. The highest possible total for the whole test would be sixty-three. This would mean you circled number three on all twenty-one questions. Since the lowest possible score for each question is zero, the lowest possible score for the test would be zero. This would mean you circle zero on each question.

You can evaluate your depression according to the Table below.

Total Score	Level of depression
1-10	These ups and downs are considered normal
11-16	Mild mood disturbance
17-20	Borderline clinical depression
21-30	Moderate depression
31-40	Severe depression
Over 40	Extreme depression

[cf7mls_step cf7mls_step-14 "Back" "Next" "Step 15"]

ADHD Checklist

Symptoms of Inattention (Six or more of these)

Does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities
NeverSometimesOftenVery Often

Has trouble sustaining attention in tasks or play activities
NeverSometimesOftenVery Often

Does not seem to listen when spoken to directly
NeverSometimesOftenVery Often

Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
NeverSometimesOftenVery Often

Has trouble organizing tasks and activities
NeverSometimesOftenVery Often

Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as homework)
NeverSometimesOftenVery Often

Loses things necessary for tasks or activities (tous, school assignments, pencils, books, or tools)
NeverSometimesOftenVery Often

Is easily distracted by external stimuli
NeverSometimesOftenVery Often

Is forgetful in daily activities
NeverSometimesOftenVery Often

Symptoms of Hyperactivity & Impulsivity* (Six or more of these)

Hyperactivity

Fidgets with hands or feet or squirms in seat
NeverSometimesOftenVery Often

Leaves seat in classroom or in other situations in which remaining seated is expected
NeverSometimesOftenVery Often

Runs about or climbs when and where it is inappropriate
NeverSometimesOftenVery Often

Has trouble playing quietly or enjoying leisure activities quietly
NeverSometimesOftenVery Often

Is ‘on the go’ or acts as if ‘driven by motor’
NeverSometimesOftenVery Often

Talks excessively
NeverSometimesOftenVery Often

Impulsivity

Blurts out answers before questions have been completed
NeverSometimesOftenVery Often

Has trouble waiting his or her turn
NeverSometimesOftenVery Often

Interrupts or intrudes on others (such as butting into conversations)
NeverSometimesOftenVery Often

Documentation

Upload front and back of insurance card, ID/Driver's License, and custody documentation if applicableduplicate 8
**(Patients using insurance for appointments will have to provide a copy of the front and back of insurance card prior to scheduling)duplicate 8**

Please select the documents you wish to send
IDDriver's LicenseInsurance Cards

Please, ensure that the files that you are attaching for submission do not exceed the maximum size of 10 MB. Files larger than this might cause that your files do not get to our offices along with your information.
If you do not have this any of these files in digital, you can bring them to your first consultation with our doctors.

Front Copy DL:

Upload your Files

Back Copy DL:

Upload your Files

Front Copy Photo ID:

Upload your Files

Back Copy Photo ID:

Upload your Files

Front Copy Insurance Cards:

Upload your Files

Back Copy Insurance Cards:

Upload your Files

[cf7mls_step cf7mls_step-15 "Back" "Step 15"]