Patient Information Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1Personal Details2Insurance and Pharmacy3Medical Details4Acknowledgement And DocumentsWe ask you to submit following documents. You can upload them through this form. 1. Insurance Card 2. Driving License 3. Psychological Testing Reports (if any) Is the Patient *Child/ Adolescent (below 18 years)Adult (18 years or above)Name of Patient *FirstMiddleLastPreferred NameDate of Birth *Gender *MaleFemaleOtherOther Gender *Address *Address Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell Phone *Email *Name of Parent *FirstMiddleLastParent's Phone *Parent's Alternate PhoneParent's Email *Parents are *MarriedSingleDivorcedWidow/ WidowerSeparatedCustody Arrangements *Family Members Living at HomeFatherMotherBrother(s)Sister(s)SpouseOthersChild's SchoolChild's GradeRelationship of the Guarantor with the Patient *ParentOtherRelationship of the Guarantor with the Patient *SelfParentSpouseOtherOther Guarantor *Name of Guarantor *Guarantor's Date of Birth *Guarantor's AddressSame as patientGuarantor's Address, if not same *Address Line 1CityGuarantor's StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeGuarantor's Cell NumberSame as patientGuarantor's Cell NumberSame as parentGuarantor's Cell Number, if not same *Emergency Contact Name *FirstLastEmergency Contact Phone *NextDo You have a Medical Insurance? *YesNo, I will pay myselfName of Person – Primary on Insurance *FirstLastRelationship of Subscriber (Primary on Insurance) with Patient *SelfParentSpouseOtherRelationship of Subscriber (Primary on Insurance) with Patient *ParentOtherOther Subscriber *Insurance Company Name *Insurance Company Address *Address Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsurance Company Phone Number *Insurance Holder's ID Number *Insurance Holder's Group NumberSecondary Insurance I have secondary insuranceName of Person – on Secondary InsuranceFirstLastSecondary Insurance Company NameSecondary Insurance Company AddressAddress Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSecondary Insurance Company Phone NumberSecondary Insurance Holder's ID NumberSecondary Insurance Holder's Group NumberPharmacy's Name *Pharmacy's Address *Address Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePharmacy's Phone Number *PreviousNextReferred byPrincipal Reason(s) for Requesting a Treatment/ Consultation *Areas of Concern (Academic/ Work)Difficulty with peersDifficulty with authorityBehavioral problemsLearning disabilityDifficulty with focus and concentrationLanguage / speech delayHistory of current academic/work problemsAreas of Concern (Personal)Unduly sadOverly anxiousTemper tantrumsWithdrawn / shyUncontrollable habits / mannerismStrange/ bizzare behaviourSelf harmSuicidal thoughts/ behaviourHomicidal though /behaviourPerceptual/visual disturbanceProblem with self care(eating, bathing , toileting)Risk taking behaviourAreas of Concern (Family)Parent child problemMarital conflict or co-parenting problemsSibling conflictRecent family changesRecent trauma/lossDomestic violence/abuseElaborate Areas of ConcernCurrent Medical Illnesses *Prior Psychiatric Diagnosis/ TreatmentMedication Allergies and Reactions *Prior/ Current Primary Care PhysicianPrior/ Current Primary Care Therapist Prior/ Current Mental Health Provider Or PsychiatristPast Treatment HistoryPartial HospitalisationIntensive Outpatient ProgramsHospitalizationNoneMonth/ Year and Reason for HospitalizationFamily Psychiatric HistoryList Past/ Current Psychiatric Medications Including Maximum Dosages and Frequency *PreviousNextWe encourage you to upload following documents for faster processing. If you are unable to share the documents now, you can send them via Email at [email protected] Insurance Card – Front Side Click or drag a file to this area to upload. Insurance Card – Back Side Click or drag a file to this area to upload. Driving License Click or drag a file to this area to upload. Psychological Testing Reports Click or drag a file to this area to upload. Integrated Psychiatric Services Payment and Office Policies * Payment and office Policies *I have read and understood the Payment and Office Policies of Integrated Psychiatric Services. I agree to pay for services under the conditions and specifications set forth in this billing policy and acknowledge that I am responsible for payment of all services provided, regardless of insurance coverage.Integrated Psychiatric Services HIPAA Policies * HIPAA Policy *I acknowledge that I have read and fully understand the Integrated Psychiatric Services HIPAA Policies.Release of Information *I agree to following terms of release of information *I hereby authorize Integrated Psychiatric Services (IPS) to release and/or obtain information from the records- Psychiatric Evaluation, Medication evaluation, Ongoing Treatment, Insurance Request/Claims. The information to be released and/or obtained includes all or some of the following: 1. Psychiatric Evaluation, Progress Notes, Course of Treatment, Medication History, Psychosocial History, Hospitalization Course, Discharge Summary 2. Psychological Testing Reports 3. Medical/Surgical Records 4. School Records 5. Lab/Imaging Reports 6. Juvenile Court Records 7. Other social agency reports. Authorization will remain in effect for: The time necessary to complete my treatment or Court mandate. I understand that in order to protect confidentiality, my agreement to obtain and/or release information is necessary, and this permission is limited for the purposes and to the person listed above. I also understand that unless otherwise limited by state or federal regulations (such as court mandate) I can cancel this consent at any time, except for action, which has already been taken.Consent for Treatment *I agree to following terms of consent for treatment *Permission is hereby given for any medical/surgical procedure, X-rays, drug or laboratory test, medication, or exam as may be deemed necessary by the Psychiatrist, Physician Assistant, or Nurse Practitioner. I understand I have the right to see a psychiatrist if I choose and have the right to see a psychiatrist prior to any prescription drug or device order being carried out by an Advanced Practitioner. In the case of an unemancipated minor, the consent below is being given on his or her behalf.Privacy Policy *I agree to following privacy policy *Acknowledgement of Privacy Rights: By signing below, I acknowledge that I am aware of the Integrated Psychiatric Services (IPS) Notice of Privacy Practices and Individual Rights. We may use or share your medical information with personnel involved in your care at IPS. We may disclose your medical information to people outside of the system, such as Health Information Exchanges. IPS Notice of Privacy Practices contains more information about the policies and practices protecting the patient’s privacy. I acknowledge that I have read the above, am giving my consent to the above, and am acknowledging I have been informed of my rights to privacy.PreviousSubmit
