New Patient Pre-Assessment For new patients, complete the form below. You'll want to set aside at least 30 minutes to complete. Step 1 of 10 - Face Sheet I 10% 1. Client DemographicsFull Name:* First Middle Last Sex:*MFDOB:* MM DD YYYY Age:*Marital Status:*SingleWidowedMarriedDivorcedSeparatedEthnic Origin:*HispanicNon-HispanicAddress:* Street Address City State / Province / Region ZIP / Postal Code Race:*African-AmericanAsianWhiteNative AmericanReligion:Home Phone:Cell Phone:*Social Security #:*Driver's License / State (if applicable):Employer Name:*Occupation:Length of Employment:Employer Phone:Highest Level of Education (current grade level):*Degree Obtained:Primary Care Physician Name:Address/City:Phone # / Fax #:Preferred Pharmacy / Phone:2. Guarantor / Legal Guardian / Parent of Minor:Name: First Last Sex:MFDOB: MM DD YYYY Relation:Cell Phone:Social Security #:Occupation:Address: Street Address City State / Province / Region ZIP / Postal Code Employer Name:Length of Employment:Employer Phone:3. Primary Insurance Information:Name of Insurance:*Insurance Phone:*Policy / Hic #:Social Security #:*Group Name:Group #:Insured's Full Name* First Middle Last Sex:*MFDOB:* MM DD YYYY Relation:Employer Name:Occupation:Length of Employment:Employer Phone:Employer Address: Street Address City State / Province / Region ZIP / Postal Code 4. Secondary Insurance:Do you have secondary insurance?YesNoName of Insurance:*Insurance Phone:*Policy / Hic #:Social Security #:*Group Name:Group #:Insured's Full Name* First Middle Last Sex:*MFDOB:* MM DD YYYY Relation:5. Please describe the problem that brought you here today.Please describe briefly the problem that brought you here today.* 6. Emergency ContactEmergency Contact #1:*Relationship:*Address* Street Address City State / Province / Region ZIP / Postal Code Best Contact Phone:*For minors, if parents are not together and patient has contact with non-custodial parent, please provide parent’s name and include status of custody arrangement.2nd Parent Name:Relationship to Patient:Status of Custody Arrangement:Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Contact Phone:7. Previous Mental Health or Chemical Dependency Hospitalizations:Last 12 months:YesNoWhere:When:Why:How long:Last 6 months:YesNoWhere:When:Why:How long:8. How did you hear of Mind Above Matter?How did you hear about Mind Above Matter?Mental Health ProfessionalLegal / JudicialPsychiatristClergy / ChurchFamily / FriendInternetInsurance CompanyA Previous PatientAdvertisementOrganization9. Specific names of individuals/organizations who referred you:Name:Relationship to Patient / Title:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country PhonePermission to contact:YesNo10. If patient is a minor, provide information on patient’s school.School Name / District:Homeroom / Primary Teacher Name:Address: Street Address City State / Province / Region ZIP / Postal Code Phone:Permission to contact:YesNoTo identify persons supporting and using services; notification of admission, discharge, and aftercare plans. All requested information must be completed for insurance claims to be correctly processed. Exclusion of insurance policy information may result in an insurance denial in which you will be totally responsible for your bill. The person who signs consent is the Guarantor/responsible party for this bill. I authorize the release of any medical or other information necessary to process this claim to my insurance company. This may also include case managers with your insurance company. I also authorize payment of medical benefits to Mind Above Matter LLC, for services rendered to me.Signature*Date* MM DD YYYY Current problems and concerns:Please indicate the symptoms you have experienced in the past 3 months by circling the level of intensity. 1 = Absent or Low 2 = Moderate 3 = Severe Depression*123Feeling hopeless*123Obsessions/Compulsions*123Extreme sadness*123Trouble concentrating*123Feeling stressed*123Memory problems*123Lack of energy*123Feeling extremely happy*123Self-esteem problems*123Easily irritated*123Change in sexual interest/functioning*123Thoughts/actions of self harm*123Perfectionism*123Feeling worthless*123Anger problems*123Feeling fearful*123Feeling anxious*123Acting violently*123Feeling tearful*123Muscle tension*123Isolating from others*123Social anxiety*123Avoidance*123Problems getting along with family*123Thoughts/actions of killing self*123Trouble doing work*123Sudden feelings of panic*123Physical complaints of pain*123Difficulty sitting still*123Difficulty finishing work*123Always on the go*123Constant inner restlessness*123Oppositional/argumentative*123Excessive worrying*123Acting recklessly/dangerously*123Racing thoughts*123Lack of enjoyment/no motivation*123Thoughts of harming/killing others*123Lifestyle InformationSLEEPING: Difficulty going to sleep Difficulty staying asleep Early AM awakening Nightmares Sleeping during the day No difficulty sleeping Hours of sleeping on average:Duration of sleep symptoms:Days / MonthsConsistent physical exercise? Consistent physical exercise APPETITE / EATING: Decreased Increased Binge eating / overeating Poor nutrition Skipping meals History of eating disorders?YesNoType:Recent weight gain? Recent weight gain? How much?lbs.In last:days / monthsRecent weight loss? Recent weight loss? How much?lbs.In last:days / monthsALCOHOL USE: Decreased Increased Binge drinking / overdrinking Impacting social / work life Legal issues History of alcohol abuse?YesNoAverage amount consumed/day:Last time drank:How much?TOBACCO USE: Decreased Increased Impacting social / work life Average amount used / day:Type:Last time used:How much?DRUG USE: Decreased Increased Binge using / overusing Impacting social / work life Legal involvement History of drug abuse?YesNoAverage amount used / day:Type:Last time used:How much? Previous Mental Health Treatment Information:Previous / Current Psychiatrist:Phone:Last Seen:Previous / Current Psychiatrist:Phone:Last Seen:Medical InformationPrescription/Non-Prescription medication(s) you are currently taking:Name of MedicationDosageDirections (ex. How many times a day, route)Date of Initial RxMedical or Mental Health? Medication Allergies:Other Allergies:Past/Current Medical Problems: Asthma High blood pressure High cholesterol Hyper / hypothyroidism GERD Diabetes Stroke Cancer Immune System Disorder Other Cancer Type:Immune System Disorder Type:Other, please specify:Past Surgeries:Surgery TypeYear Past hospitalizations (excluding surgeries):ReasonYear Concussions:YesNoSeizures:YesNoHousehold Information:Please list the individuals with whom you resideHousehold InformationNameAgeRelationship to PatientQuality of Relationship If patient is a minor, status of patient’s parents:SingleLegally MarriedRemarriedSeparatedDivorcedWidowedMost current custody agreement is required upon assessment. Did you bring it today?YesNoCustody Agreement File Upload: Drop files here or Accepted file types: jpg, png, pdf, gif. (Maximum of 5 files, 100MB Limit)Other Important InformationAny history of abuse (physical, emotional, or sexual)?*YesNoUnsureAny current parole, probation, pending legal charges, etc?*YesNoUnsure Assessment Service Disclosure Statement and Consent to AssessmentMind Above Matter lawfully and ethically operates an assessment service by a licensed mental health professional. The clinician may refer appropriate patients for outpatient treatment or to a physician for further evaluation or recommend admission to the facility. Before referring and/or assessing a person, the following disclosures must be made to each person seeking treatment or assessment: Mind Above Matter is not obligated to provide an assessment by a physician unless deemed necessary by the assessment clinician. Physician assessments are billable services. This assessment is voluntary and the client is free to choose whether they want to pursue further treatment. The assessment clinician is an employee of Mind Above Matter. The assessment is confidential unless the client gives permission in writing to release information. Specific mental health professionals the client may be referred to are licensed and meet clinical and ethical standards of the hospital. Financial reimbursements are never given or received by Mind Above Matter based on referrals. I certify that I have read and fully understand the above consent for assessment. I agree to absolve Mind Above Matter and its staff rending the treatment(s) from any liability.I certify that I am:*ClientBiological parent with authority to consent for treatmentAdoptive ParentFoster ParentLegal Guardian(papers are required)IN CASES INVOLVING DIVORCE/ADOPTION OR FOSTER PARENT ARRANGEMENT PAPERS MUST BE PRESENTED PRIOR TO CONSENT FOR ASSESSMENT.For all minor clients: Is there a divorce decree, custody agreement, or adoption papers?(Select one option, and initial)YesNoInitialIf yes, has a copy of the decree/agreement been provided to MAM?YesNoDate: MM DD YYYY Arrangement Papers Upload: Drop files here or Accepted file types: jpg, gif, png, pdf. (For cases involving divorce, adoption or foster parent)Choice*I Consent to AssessmentI Refuse AssessmentSignature of Individual Consenting or Refusing Assessment / Medical Screening:*Parent / Legal Guardian Signature:*Date* MM DD YYYY Limits of ConfidentialityContents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows: Duty to Warn and Protect When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. Abuse of Children and Vulnerable Adults If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. Prenatal Exposure to Controlled Substances Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. Minors/Guardianship Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records. Insurance Providers (when applicable) Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.* I agree to the above limits of confidentiality and understand their meanings and ramifications. Client Signature (Client’s Parent/Guardian if under 18)*Date* MM DD YYYY Physician Ownership DisclosureDuring the course of your treatment at Mind Above Matter (“MAM”), you may be treated by a physician or other provider that has an ownership interest in MAM. After you finish your treatment program with MAM, you have the option of seeking on-going treatment with one of MAM’s physicians or providers or another provider who is not affiliated with MAM. This information is being provided to you to help you make an informed decision about your health care. You have the right to choose your health care provider. You have the option of obtaining health care ordered by your physician from a different provider or at a different facility. You will not be treated differently by your physician or MAM if you choose to use a different physician/provider. If desired, your physician can provide information about alternative providers. If you have any questions concerning this notice, please feel free to contact Holly Sojourner at 817-447-3001. By signing below you acknowledge that should you be referred for further treatment, you understand your rights to choose your own provider.Client Signature:*Printed Name of Client:*Date* MM DD YYYY General Consent for TreatmentTO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended psychiatric, 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, laboratory testing including urine drug screens and blood work, 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 provider 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 health care provider, we encourage you to ask questions. I voluntarily request a physician, and/or nurse practitioner 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).General Consent for Treatment<p><i>TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended psychiatric, 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).</i></p> <p>This consent provides us with your permission to perform reasonable and necessary medical examinations, laboratory testing including urine drug screens and blood work, 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.</p> <p>You have the right to discuss the treatment plan with your provider 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 health care provider, we encourage you to ask questions.</p> <p>I voluntarily request a physician, and/or nurse practitioner 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).</p>Consent* I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. Signature of Client or Personal Representative:*Date:* MM DD YYYY Printed Name of Patient or Personal Representative:*Relationship to Patient: Notice of Receipt of HIPAA Notice of Privacy PracticesThe undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.Client / Legal Guardian Signature:*Date:* MM DD YYYY Notice of Receipt of Registration/No Show/Termination PolicyThe undersigned acknowledges receipt of a copy of the currently effective Receipt of Registration/No Show/Termination/Grievance Policy for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.Client / Legal Guardian Signature:*Date:* MM DD YYYY PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR/YOUR CHILD’S HEALTH INFORMATION:(This includes non-custodial parents, step parents, grandparents and any care takers who can have access to this client’s records):Name:Relationship: I authorize contact from this office to confirm my appointments, treatment, and billing information via: Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Email Confirmation Email* Cell Phone:*Home Phone:*Work Phone:*Client / Legal Guardian Signature:*Date:* MM DD YYYY Informed Consent for Telehealth ServicesClient Name:*Location of Client:*Date of Birth:* MM DD YYYY Informed Consent for Telehealth ServicesInformed Consent for Telehealth Services This consent form is incorporated into the Informed Consent to Treatment Form signed as part of initiating or continuing services with Mind Above Matter or with any of the subsidiary programs of Mind Above Matter. The following information is provided to clients who are seeking Telehealth services or who may utilize this service at any point in the future. This document covers your rights, risks and benefits associated with receiving services delivered via telehealth. What is Telehealth? “Telehealth” means, in short, provision of mental health services with the provider and recipient of services being in separate locations, and the services being delivered over electronic media. Services delivered via telehealth rely on a number of electronic, often Internet-based, technology tools. These tools can include videoconferencing software, email, text messaging, virtual environments, specialized mobile health (“mHealth”) apps, and others. You will need access to Internet service and technological tools to engage in telehealth work with your provider. If you have any questions or concerns about the necessary tools, please address them directly to your provider so you can discuss their risks, benefits, and specific application to your treatment. Benefits and Risks of Telehealth Receiving services with telehealth allows you to: Receive services at times or in places where the service may not otherwise be available. Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings. Receive services when you are unable to travel to the service provider’s office. The unique characteristics of telehealth media may also help some people make improved progress on health goals that may not have been otherwise achievable without telehealth. Receiving services via telehealth has the following risks: Telehealth services can be impacted by technical failures, may introduce risks to your privacy, and may reduce your service provider’s ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples: Internet connections and cloud services could cease working or become too unstable to use Cloud-based service personnel, IT assistants, and malicious actors (“hackers”) may have the ability to access your private information that is transmitted or stored in the process of telehealth-based service delivery. Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out. Interruptions may disrupt services at important moments, and your provider may be unable to reach you quickly or using the most effective tools. Your provider may also be unable to help you in-person. There may be additional benefits and risks to telehealth services that arise from the lack of in-person contact or presence, the distance between you and your provider at the time of service, and the technological tools used to deliver services. Your provider will assess these potential benefits and risks, sometimes in collaboration with you, as your relationship progresses. Assessing Telehealth’s Fit For You Although it is well validated by research, service delivery via telehealth is not a good fit for every person. Your provider will continuously assess if working via telehealth is appropriate for your case. If it is not appropriate, your provider will help you find in-person providers with whom to continue services. Please talk to your provider if you find the telehealth media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the telehealth medium seems to be causing problems in receiving services. Raising your questions or concerns will not, by itself, result in termination of services. Bringing your concerns to your provider is often a part of the process. You also have a right to stop receiving services by telehealth at any time without prejudice. If your provider also provides services in-person and you are reasonably able to access the provider’s in-person services, you will not be prevented from accessing those services if you choose to stop using telehealth. Your Telemental Health Environment You will be responsible for creating a safe and confidential space during sessions. You should use a space that is free of other people. It should also be difficult or impossible for people outside the space to see or hear your interactions with your provider during the session. If you are unsure of how to do this, please ask your provider for assistance. Our Communication Plan In case of technology failures the best way to contact your provider between sessions is by calling (817) 447-3001. Your provider will respond to your messages within 24 hours. Please note that your provider may not respond at all on weekends or holidays. Your provider may also respond sooner than stated in this policy. That does not mean they will always respond that quickly. Your provider is located in the Central time zone. Please note the time difference from your own time zone. Please note that all textual messages you exchange with your provider, e.g. emails and text messages, will become a part of your health record. Your provider may coordinate care with one or more of your other providers. Your provider will use reasonable care to ensure that those communications are secure and that they safeguard your privacy. Our Safety and Emergency Plan As a recipient of telehealth-based services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with your provider. Your provider will require you to designate an emergency contact. You will need to provide permission for your provider to communicate with this person about your care during emergencies. Your provider will also develop with you a plan for what to do during mental health crises and emergencies, and a plan for how to keep your space safe during sessions. It is important that you engage with your provider in the creation of these plans and that you follow them when you need to. Your Security and Privacy Except where otherwise noted, your provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged. As with all things in telehealth, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with your provider, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that your provider has supplied for communications. Recordings Please do not record video or audio sessions without your provider’s consent. Making recordings can quickly and easily compromise your privacy, and should be done so with great care. Your provider will not record video or audio sessions. Patient Consent For The Use of Telehealth* I have read and understand the information provided above regarding telehealth, have discussed it with my physician, therapist, provider, or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my medical and mental health care. * I hereby authorize Mind Above Matter, and any of its providers, to use telehealth in the course of my diagnosis and treatment. Client / Legal Guardian Signature:*Date:* MM DD YYYY I have been offered a copy of this consent form.patient's initials This iframe contains the logic required to handle Ajax powered Gravity Forms.