I authorize the Center for ADHD, Inc./R. Timothy Brown, M.D. to evaluate and treat.

Transcription

1 CENTER FOR ADHD, INC. AND R. TIMOTHY BROWN, M.D., LLC Consent to Evaluate and Treat Date: Patient: Age: Date of Birth: Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Business/Cell Phone: Person(s) Responsible for Payment: Relationship to Patient: Address (if different from patient) City, State, Zip Code: Home Phone: Business/Cell Phone: I authorize the Center for ADHD, Inc./R. Timothy Brown, M.D. to evaluate and treat. Relationship to Patient: Signature: Witness: Date: Date: Form:consent 02/03/2006

2 R. Timothy Brown, M.D., LLC Financial Policy Agreement We believe that everyone benefits when there is a clear and definite understanding of our financial policy prior to treatment. 1. PATIENTS WITHOUT INSURANCE: All patients without insurance are required to pay in full for the service rendered at the time of the appointment. 2, ALL PATIENTS WITH MANAGED CARE PLANS: It is your responsibility to know and understand your managed care plan. Generally, these plans require payment of deductibles and/or copayments. Patients are required to pay for services according to their insurance contract at time of service. 3. ALL PATIENTS WITH INSURANCE: If our office is contracted with your insurance company, we will file your insurance claims if you provide us with the proper information along with a copy of your current insurance card. In the event your insurance overpays, we will refund the overpayments to you promptly upon written request. Otherwise, overpayments will be credited to your account for future services. If your insurance company does not pay within 60 days, you are responsible for the remaining balance and you will be billed accordingly. 4. CANCELLATION POLICY: There is a charge for failed appointments/late cancellations of appointments when less than a 24 hour notice is given by the patient. You will be charged the full fee for the service which would have been rendered. Reminder calls to our patients are offered as a courtesy. 5. QUESTIONS: You are encouraged to call our office if there are any questions about this information. If at any time during treatment of the patient, financial problems arise, you are encouraged to speak with our office. 6. Payment for services rendered may be made by check, cash or credit card (Master Card or Visa). I have read and agree with the terms of this agreement. Responsible Party Signature: Date: ASSIGNMENT OF BENEFITS I authorize payment of insurance benefits to R. Timothy Brown, M.D., LLC for services rendered. Responsible Party Signature: Date: Form.financial 12/12/03

3 CREDIT CARD CONSENT POLICY FORM I the undersigned authorize The Center for ADHD, Inc. to keep my signature on file and to charge my credit/debit card account as indicated below: VISA MASTERCARD A charge to the credit/debit card will ONLY be made under the following circumstances: 1. Missed appointments 2. Cancellations made less than 24 hours from time of scheduled appointment 3. Any claims that are denied secondary to insurance not being in effect at the time of service 4. Any claim that is applied toward a deductible 5. Any claim that is denied secondary to failure on the part of the patient/patient s responsible party to obtain proper authorization or referral and/or failure to complete forms required by insurance company needed to process claim 6. Any claim that becomes more than 120 days past due after proper filing and at least 1 refilling by this office Charges will be as follows: 1. Initial evaluation $ minute follow up visit $ Medication management $ minute psychotherapy visit $195 I the undersigned understand that this form will be valid for the duration of my treatment with this office UNLESS I cancel through written notice to The Center for ADHD, Inc., 2124 Monroe St. Mandeville, LA Patient Name Cardholder Name Cardholder billing address Credit Card Number Mo. Yr. Expiration date Cardholder Signature Date

4 CENTER FOR ADHD, INC. AND R. TIMOTHY BROWN, M.D., LLC I value you as a patient of my practice and am committed to providing safe and effective mental health services to you. I want to make sure that you are aware of your rights and responsibilities as a patient. I believe that by doing so, you will be able to best work with me and the office staff in your treatment. AS A PATIENT, YOU HAVE THE RIGHT TO: Considerate and courteous care by the office staff and physician. Privacy and confidentiality about your care, treatment and records. Respect for your time - be greeted upon arrival & kept informed regarding the approximate waiting time. A safe and comfortable environment for your care. Complete and current information regarding your diagnosis, treatment and prognosis; the nature and purpose of tests, prescribed therapy and/or medications, and potential adverse effects associated with the treatment plan. Clear instructions concerning the need for follow-up visits, referral to other mental health professionals, or additional measures necessary to achieve the desired outcome for your diagnosis. Accept or refuse any or all of the treatment plan after receiving a complete explanation. Additional professional opinion(s) on any diagnosis or recommended treatment plan. A copy of medical records pertaining to your treatment after payment of reasonable copying fees and account balances, if any. Information about your account, the amount and purpose of charges and our policies regarding payment of charges as well as procedures for resolving conflicts in the settlement of the account. AS A PATIENT, YOU HAVE THE RESPONSIBILITY TO: Provide correct, complete information about your health. Follow the treatment plan ordered by your physician, unless you notify him of concerns. Consider the rights of other patients and office personnel. Follow office rules and regulations that apply to patient conduct. Take responsibility for your actions if you refuse treatment or do not follow your physician s instructions. Meet the financial obligations for your care as soon as possible. Call the office if unable to keep scheduled appointments and arrive on time for scheduled appointment. We want to make sure that you are satisfied with the care you receive from your physician and office staff. If you have questions or concerns, you may speak with the office staff or physician. I acknowledge that I have read and understand this Notice of Privacy Practices. Patient s Name: Signature of Patient: DOB: Date: If patient is a minor, Parent/Guardian: Form:hippa 2/3/2006

5 ACKNOWLEDGE OF RECEIPT OF NOTICE OF PRIVACY PRACTICES PATIENT S NAME: DOB: SIGNATURE OF PATIENT DATE IF PATIENT IS A MINOR SIGNATURE OF PARENT/GUARDIAN

6 ADULT INTAKE INFORMATION BASIC INFORMATION NAME: DATE: GENDER (circle one): Male Female RACE (circle one): White Black Other BIRTH DATE: HOME ADDRESS: AGE: years Place of Business: City: State: Zip: ADDRESS: HOME PHONE: BUSINESS PHONE: WHO REFERRED YOU HERE? BUSINESS PHONE: ADDRESS: PHONE: PRESENTING PROBLEMS Briefly describe your current difficulties: How long has this been of concern to youi? When was this problem first noticed? What seems to help the problem? What seems to make the problem worse? Have any other family members had similar problems? Yes No If yes, whom? Have you received evaluation or treatment for the current problem or similar problems? Yes No If yes, when and with whom? If currently, list address: Are you on any medication at this time? Yes No If yes, please write name(s):

7 Describe any major event(s) that might be related to the problem ( e.g. death, divorce, abuse, etc.): DEVELOPMENTAL HISTORY As far as you know, were there any problems with your mother s pregnancy or delivery of you? Yes No If yes. Details: As far as you know, did you walk, talk, and sit up on time? Yes No If no, details: Did you have any childhood illnesses? Yes No If yes, details: Did you have normal relationships with your peers when you were a child? Yes No If no, details: EDUCATIONAL HISTORY Schools Attended: Dates Degrees Universities: High School: Special Education (yes / no ) If yes, type of class Please list medications below: MEDICAL HISTORY MEDICATION AGE REASON PRESCRIBED Have you ever suffered from a head injury which caused confusion or loss of consciousness? Yes No

8 Place a check next to any illness or condition that you have had. When you check an item, also note the approximate date or age at the time of the illness. ILLNESS OR CONDITION AGE OR DATES ILLNESS OR CONDITION AGE OR DATES AIDS or HIV positive Fainting Spells Allergies Fetal Alcohol Syndrome Anemia Fever (if high or prolonged) Aneurysm Guillain-Barre Syndrome Anoxia Head Injury Arteriovenous Malformation Headaches Arthritis Heart Disease or Problems Asthma Lead Poisoning Ataxia Hepatitis Automobile Accident Herpes Back Pains or Problems High Blood Pressure Bleeding Problems Jaundice Blood Disorders Leukemia Bone or Joint Disease Malnutrition Broken Bones Meningitis Cancer Muscular Disease Chorea Pain Problems Coma Paralysis Cystic Fibrosis Pituitary Disorder Dazed or Unconscious Pneumonia Dementia Poisoning Diabetes Poliomyelitis Dysarthria Rheumatic Fever Dyspraxia (or Apraxia) Scarlet Fever Ear Infections (PE Tubes) Sensory Loss Other Ear Problems Sexual Molestation Eczema or Hives Sexually Transmitted Disease Electrical or Chemical Shock Speech and Language Problems Encephalitis Spells( ) Epilepsy, Seizures, Fits Stroke Suicide Attempts or Thoughts Indicate if you have undergone any of these medical Tests(please check and give age): Sunstroke or Heat Exhaustion Thyroid Disorder or Problem Trauma ( ) Electroencephalogram (EEG) Tuberculosis Skull X-rays Tumor CT Scan Visual Problems MRI Scan Whooping Cough BRAM Study Evoked Potentials OTHER MEDICAL PROBLEM(S): Ophthalmologic (Vision) Audiological Evaluation Medication allergies Physician s name and address:

9 Are there any medical illnesses that run in your family? Yes No If yes, details: Is there any one in your family who has had problems with anxiety or depression? Yes No If yes, details: Is there anyone in your family who has abused alchol or other drugs? Yes No If yes, details: Is there anyone in your family who has had psychiatric illness? Yes No If yes, details: Is there anyone in your family who has been in trouble with the law? Yes No If yes details: Is there anyone in your family who has had seizures or other neurological problems? Yes No If yes details: Is there anyone in your family who has had Tourette s syndrome or vocal tics? Yes No If yes details: Is there anyone in your family who has movement disorder or any unusual movements? Yes No If yes details: Is there anyone in your family who has heart problems? Yes No If yes details: Is there anyone in your family who has high blood pressure? Yes No If yes details: Is there anyone in your family who has had attentional problems? Yes No If yes details: Is there anyone in your family who has had learning disabilities? Yes No If yes details:

10 SOCIAL HISTORY How much do you smoke? a. Never smoked e. Half to one ppd b. Have quit for more than a year? e. Half to one ppd c. Have quit for less than a year f. One to two ppd d. less than half pack per day (ppd) How much caffeine do you drink, including caffeinated tea and soda? a. None d. 5-6 cups per day b. 1-2 cups per day e cups per day c. 3-4 cups per day f. 11+ cups per day Breifly describe your work history, starting as far back as you can remember. Have you ever been in trouble with the law? Yes No Describe: What is your current marital status List names and ages of children a. Never married d. Divorced b. Married e. Widowed c. Separated Are you currently in an intimate relationship? Yes No If yes, for how long? a. Less than 3 months? d. 1-5 years b. 3-6 months e years c. 7 months - 1 year f. 10+ years Do you have trouble in your relationship with others? Yes No If yes, details: How many intimate relationships with others? a. None c. Three or four b. One or two d. Five or more You have been asked a lot of questions. Can you think for a minute and describe any other problems you have that might be related to what you came here for?

11 ADULT ADHD SELF-REPORT SCALE (ASRS-V1.1) SYMPTOM CHECKLIST Patient Name Today s Date Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today s appointment. PART A Never Rarely Sometimes Often Very Often 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? 3. How often do you have problems remembering appointments or obligations? 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? PART B 7. How often do you make careless mistakes when you have to work on a boring or difficult project? 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? 10. How often do you misplace or have difficulty finding things at home or at work? 11. How often are you distracted by activity or noise around you? 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? 13. How often do you feel restless or fidgety? 14. How often do you have difficulty unwinding and relaxing when you have time to yourself? 15. How often do you find yourself talking too much when you are in social situations? 16. When you re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? 17. How often do you have difficulty waiting your turn in situations when turn taking is required? 18. How often do you interrupt others when they are busy? Adapted with permission 2004 World Health Organization

12 BSDS1_Scale.lay 10/2/08 2:52 PM Page 2 THE BIPOLAR SPECTRUM DIAGNOSTIC SCALE (BSDS) Instructions: Please read through the entire passage below before filling in any blanks. Some individuals notice that their mood and/or energy levels shift drastically from time to time. These individuals notice that, at times, their mood and/or energy level is very low, and at other times, very high. During their ''low'' phases, these individuals often feel a lack of energy; a need to stay in bed or get extra sleep; and little or no motivation to do things they need to do. They often put on weight during these periods. During their low phases, these individuals often feel ''blue'', sad all the time, or depressed. Sometimes, during these low phases, they feel hopeless or even suicidal. Their ability to function at work or socially is impaired. Typically, these low phases last for a few weeks, but sometimes they last only a few days. Individuals with this type of pattern may experience a period of ''normal'' mood in between mood swings, during which their mood and energy level feels ''right'' and their ability to function is not disturbed. They may then notice a marked shift or ''switch'' in the way they feel. Their energy increases above what is normal for them, and they often get many things done they would not ordinarily be able to do. Sometimes, during these ''high'' periods, these individuals feel as if they have too much energy or feel ''hyper''. Some individuals, during these high periods, may feel irritable, ''on edge'', or aggressive. Some individuals, during these high periods, take on too many activities at once. During these high periods, some individuals may spend money in ways that cause them trouble. They may be more talkative, outgoing, or sexual during these periods. Sometimes, their behavior during these high periods seems strange or annoying to others. Sometimes, these individuals get into difficulty with co-workers or the police, during these high periods. Sometimes, they increase their alcohol or non-prescription drug use during these high periods. Now that you have read this passage, please check one of the following four boxes: ( ) This story fits me very well, or almost perfectly ( ) This story fits me fairly well ( ) This story fits me to some degree, but not in most respects ( ) This story does not really describe me at all Now please go back and put a check after each sentence that definitely describes you. Scoring: each sentence checked is worth one point. Add 6 points for fits me very well, 4 points for fits me fairly well, and 2 points for fits me to some degree. Total Score =

13 MOOD DISORDER QUESTIONNAIRE (MDQ) I N S T R U C T I O N S : Please answer each question as best you can. Yes No 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? you were so irritable that you shouted at people or started fights or arguments? you felt much more self-confident than usual? you got much less sleep than usual and found that you didn t really miss it? you were more talkative or spoke much faster than usual? thoughts raced through your head or you couldn t slow your mind down? you were so easily distracted by things around you that you had trouble concentrating or staying on track? you had much more energy than usual? you were much more active or did many more things than usual? you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? you were much more interested in sex than usual? you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? spending money got you or your family in trouble? 2 If 3 How you checked YES to more than one of the above, have several of these ever happened during the same period of time? much of a problem did any of these cause you like being unable to work; having family, money or legal trouble; getting into arguments or fights? No problem Minor problem Moderate problem Serious problem

14 ZUNG SELF-RATING DEPRESSION SCALE Patient s Initials Date of Assessment Please read each statement and decide how much of the time the statement describes how you have been feeling during the past several days. A little of Some of Good part Most of Make check mark ( ) in appropriate column. the time the time of the time the time 1. I feel down-hearted and blue 2. Morning is when I feel the best 3. I have crying spells or feel like it 4. I have trouble sleeping at night 5. I eat as much as I used to 6. I still enjoy sex 7. I notice that I am losing weight 8. I have trouble with constipation 9. My heart beats faster than usual 10. I get tired for no reason 11. My mind is as clear as it used to be 12. I find it easy to do the things I used to 13. I am restless and can t keep still 14. I feel hopeful about the future 15. I am more irritable than usual 16. I find it easy to make decisions 17. I feel that I am useful and needed 18. My life is pretty full 19. I feel that others would be better off if I were dead 20. I still enjoy the things I used to do Adapted from Zung, A self-rating depression scale, Arch Gen Psychiatry, 1965;12: Presented as a service by Glaxo Wellcome Inc. Research Triangle Park, NC Web site: Glaxo Wellcome Inc. All rights reserved. Printed in USA. WEL056R0 February 1997

15 KEY TO SCORING THE ZUNG SELF-RATING DEPRESSION SCALE Consult this key for the value (1-4) that correlates with patients responses to each statement. Add up the numbers for a total score. Most people with depression score between 50 and 69. The highest possible score is A little of Some of Good part Most of Make check mark ( ) in appropriate column. the time the time of the time the time 1. I feel down-hearted and blue Morning is when I feel the best I have crying spells or feel like it I have trouble sleeping at night I eat as much as I used to I still enjoy sex I notice that I am losing weight I have trouble with constipation My heart beats faster than usual I get tired for no reason My mind is as clear as it used to be I find it easy to do the things I used to I am restless and can t keep still I feel hopeful about the future I am more irritable than usual I find it easy to make decisions I feel that I am useful and needed My life is pretty full I feel that others would be better off if I were dead I still enjoy the things I used to do Adapted from Zung. 2 References: 1. Carroll BJ, Fielding JM, Blashki TG. Depression rating scales: a critical review. Arch Gen Psychiatry. 1973; 28: Zung WWK. A self-rating depression scale. Arch Gen Psychiatry. 1965;12: Presented as a service by Glaxo Wellcome Inc. Research Triangle Park, NC Web site: Glaxo Wellcome Inc. All rights reserved. Printed in USA. WEL365R0 July 1997

16 Liebowitz Social Anxiety Scale Liebowitz MR. Social Phobia. Mod Probl Pharmacopsychiatry 1987;22: Pt Name: Pt ID #: Date: Clinic #: Assessment point: Fear or Anxiety: Avoidance: 0 = None 0 = Never (0%) 1 = Mild 1 = Occasionally (1 33%) 2 = Moderate 2 = Often (33 67%) 3 = Severe 3 = Usually (67 100%) Fear or Avoidance Anxiety 1. Telephoning in public. (P) Participating in small groups. (P) Eating in public places. (P) Drinking with others in public places. (P) Talking to people in authority. (S) Acting, performing or giving a talk in front of an audience. (P) Going to a party. (S) Working while being observed. (P) Writing while being observed. (P) Calling someone you don t know very well. (S) Talking with people you don t know very well. (S) Meeting strangers. (S) Urinating in a public bathroom. (P) Entering a room when others are already seated. (P) Being the center of attention. (S) Speaking up at a meeting. (P) Taking a test. (P) Expressing a disagreement or disapproval to people you don t 18. know very well. (S) 19. Looking at people you don t know very well in the eyes. (S) Giving a report to a group. (P) Trying to pick up someone. (P) Returning goods to a store. (S) Giving a party. (S) Resisting a high pressure salesperson. (S) 24.

17 ZUNG SELF-RATED ANXIETY SCALE From Zung, W.W.K. "Assessment of anxiety disorcers" In Fann W. et al., Phenomenology and treatment of anxiety. Spectrum; N.Y DATE: DD MM YYYY Listed below are 20 statements. Please read each one carefully and decide how much of the statement describes how you have been feeling during the past week. Circle the appropriate number for each statement. STATEMENT None or a little of the time Some of the time A good part of the time Most or all of the time 1. I feel more nervous and anxious than usual I feel afraid for no reason at all I get upset easily or feel panicky I feel like I m falling apart and going to pieces I feel that everything is all right and nothing bad will happen My arms and legs shake and tremble I am bothered by headaches, neck and back pains I feel weak and get tired easily I feel calm and can sit still easily I can feel my heart beating fast I am bothered by dizzy spells I have fainting spells or feel like it I can breathe in and out easily I get feelings of numbness and tingling in my fingers, toes I am bothered by stomach aches or indigestion I have to empty my bladder often My hands are usually warm and dry My face gets hot and blushes I fall asleep easily and get a good night s rest I have nightmares