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Call Us: 678.335.6020
Our Address: Preston Ridge Commons II, 3255 North Point Parkway, Suite 202, Alpharetta GA 30005

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Home
Our Providers
Patient Center
Services
Contact Us
Pay Your Bill

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Sample Page

Why Choose Us?

This is an example page. It’s different from a blog post because it will stay in one place and will show up in your site navigation (in most themes). Most people start with an About page that introduces them to potential site visitors. It might say something like this:

Hi there! I’m a bike messenger by day, aspiring actor by night, and this is my website. I live in Los Angeles, have a great dog named Jack, and I like piña coladas. (And gettin’ caught in the rain.)

…or something like this:

The XYZ Doohickey Company was founded in 1971, and has been providing quality doohickeys to the public ever since. Located in Gotham City, XYZ employs over 2,000 people and does all kinds of awesome things for the Gotham community.

As a new WordPress user, you should go to your dashboard to delete this page and create new pages for your content. Have fun!

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Name *

First

Middle

Last

Gender *

Male
Female
Transgender
Non binary

Date of Birth (MM/DD/YYYY) *

Parents are

Address *

City *

State *

Zip Code *

Cell Phone *

Home Phone

Work Phone

Email *

Alternate Email

Family Members Living at Home

Father
Mother
Brother/s
Sister/s

Is The Guarantor Same as Patient? *

Yes
No

If Yes, Please Skip the Guarantor’s Section

Guarantor's Name

Guarantor's Birthdate (MM/DD/YYYY)

Guarantor's Address

Guarantor's City

Guarantor's State

Guarantor's ZIP Code

Guarantor's Cell Phone

Guarantor's Alternate Phone

Insurer's Name *

Insurer's Phone *

Insurer's Address

Insurer's City

Insurer's State

Insurer's Zip Code

Insurance Holder's ID Number *

Insurance Holder's Group Number *

Does the Insured have a Secondary Insurance

Yes
No

If No, please skip the secondary insurance section.

Subscriber (Primary on Insurance)

Relationship with Patient

Secondary Insurer's Name

Secondary Insurer's Phone number

Secondary Insurer's Address

Secondary Insurer's City

Secondary Insurer's State

Secondary Insurer's Zip Code

Secondary Insurance Holder's ID Number

Secondary Insurance Holder's Group Number

Current Pharmacy *

Pharmacy's Phone Number *

Pharmacy's Address *

Pharmacy's Email *

Visit Information: Referred by:

Principal Reason for Requesting a Treatment/Consultation *

Area of Concern (Academic/Work)

Difficulty with peers
Difficulty with authority
Behavioral problems
Learning disability
Difficulty with focus and concentration
Language / speech delay
History of current academic/work problems

Areas of Concern (Personal)

Unduly sad
Overly anxious
Temper tantrums
Withdrawn / shy
Uncontrollable habits / mannerism
Strange/bizzare behaviour
Self harm
Suicidal thoughts/ behaviour
Homicidal though /behaviour
Perceptual/visual disturbance
Problem with self care(eating, bathing , toileting)
Risk taking behaviour

Areas of Concern (family)

Parent child problem
marital conflict or co-parenting problems
Sibling conflict
Recent family changes *(elaborate)
Recent trauma/loss *(elaborate)
Domestic violence/abuse *(elaborate)

*Elaborate (Family changes/trauma/loss/violence/abuse)

Current Medical Illnesses

Prior Psychiatric Diagnosis/Treatment

Medication Allergies and Reactions

Prior/Current Primary Care Physician

Prior/Current Primary Care Therapist

Prior/Current Mental Health Provider Psychiatrist

Past Treatment History

Partial Hospitalisation
Intensive Out patient Programs
Hospitalisation
None

Month/Year and Reason for Hospitalization

Has the Patient Ever had Psychological Testing?

Yes
No

If yes, then please email test results to [email protected]

Family Psychiatric History

List Past/Current Psychiatric Medications Including Maximum Dosages and Frequency

*

I have read and I understand the Billing and Office Policies . 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. Click here to view the IPS Office and Payment Policy

*

I acknowledge that I have read the Privacy Policy and I am giving my consent for using the medical information, if required. Click here to view the IPS Consent and Privacy Policy

*

I acknowledge that I have read and fully understand the HIPPA Policy. Click here to view the HIPPA Policy

Our Office

Phone: 678.335.6020
Address: Preston Ridge Commons II
3255 North Point Parkway Suite 202
Alpharetta, GA 30005
Phone:678.335.6020
Fax:678.335.2477
Email: [email protected]

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Services
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