Mindful Therapy Group 21907 64th Ave W Suite 200, Mountlake Terrace, WA 98043 206.319.4446 info@mindfultherapygroup.com www.mindfultherapygroup.com Psychiatric Intake Packet Mindful Therapy Group Psychiatric Intake Packet 1
Psychiatric Intake Form (All information on this form is strictly confidential) Please complete all information on this form and either email it back to us at info@mindfultherapygroup.com to place in your chart, OR print and bring to your first visit, along with any recent lab results. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you! Name Date Date of Birth Primary Care Physician Current Therapist/Counselor Therapist s Phone What are the problem(s) you are seeking help for? 1. 2. 3. What are your treatment goals? Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms) Depressed mood Unable to enjoy activities Sleep pattern disturbance Loss of interest Concentration/forgetfulness Change in appetite Excessive guilt Fatigue Decreased Libido/ sex drive Racing thoughts Impulsivity Increased risky behavior Increased libido Decrease need for sleep Excessive energy Increased irritability Crying spells Excessive worry Anxiety attacks Avoidance Hallucinations Suspiciousness Decreased libido Suicide Risk Assessment Have you ever had feelings or thoughts that you didn t want to live? ( ) Yes ( ) No. If YES, please answer the following. If NO, please skip to Past Psychiatric History Do you currently feel that you don t want to live? ( ) Yes ( ) No How often do you have these thoughts? When was the last time you had thoughts of dying? Has anything happened recently to make you feel this way? On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently? Would anything make it better? Have you ever thought about how you would kill yourself? Is the method you would use readily available? Have you planned a time for this? Is there anything that would stop you from killing yourself? Do you feel hopeless and /or worthless? Have you ever tried to kill or harm yourself before? Mindful Therapy Group Psychiatric Intake Packet 2
Your Medical History: Allergies Current Weight Height List ALL current prescription medications and how often you take them: (if none, write none) Medication Name Total Daily Dosage Estimated Start Date Current over-the-counter medications or supplements: Current medical problems: Past medical problems, nonpsychiatric hospitalization or surgeries Have you ever had an EKG? If yes, when. Was the EKG: normal abnormal or unknown? For women only: Date of last menstrual period Are you currently pregnant or do you think you might be pregnant?. Are you planning to get pregnant in the near future? Birth control method How many times have you been pregnant? How many live births? Do you have any concerns about your physical health that you would like to discuss with me? Date and place of last physical exam: Personal and Family Medical History: You Family Which Family Member Thyroid Disease ---------------------- ( ) Anemia-------------------------------- ( ) Liver Disease ------------------------- ( ) Chronic Fatigue ----------------------- ( ) Kidney Disease ----------------------- ( ) Diabetes -------------------------------- ( ) Asthma/respiratory problems ------ ( ) Stomach or intestinal problems --- ( ) Cancer (type) ------------------------ ( ) Fibromyalgia -------------------------- ( ) Heart Disease ------------------------- ( ) Epilepsy or seizures ------------------ ( ) Chronic Pain ------------------------- ( ) High Cholesterol -------------------- ( ) High blood pressure------------------ ( ) Head trauma -------------------------- ( ) Liver problems ----------------------- ( ) Other ---------------------------------- ( ) Mindful Therapy Group Psychiatric Intake Packet 3
Is there any additional personal or family medical history? Yes No If yes, please explain When your mother was pregnant with you, were there any complications during the pregnancy or birth? Past Psychiatric History Outpatient treatment If yes, Please describe when, by whom, and nature of treatment. Reason Dates treated By whom Psychiatric Hospitalization If yes, describe for what reason, when and where. Reason Date Hospitalized Where Past Psychiatric Medications: If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can t remember all the details, just write in what you do remember). Dates Dosage Response/Side-Effects Antidepressants Prozac (fluoxetine) Zoloft (sertraline) Luvox (fluvoxamine) Paxil (paroxetine) Celexa (citalopram) Lexapro (escitalopram) Effexor (venlafaxine) Cymbalta (duloxetine) Wellbutrin (bupropion) Remeron (mirtazapine) Serzone (nefazodone) Anafranil (clomipramine) Pamelor (nortrptyline) Tofranil (imipramine) Elavil (amitriptyline) Other Mood Stabilizers Tegretol (carbamazepine) Lithium Depakote (valproate) Lamictal (lamotrigine) Tegretol (carbamazepine) Topamax (topiramate) Other Mindful Therapy Group Psychiatric Intake Packet 4
Past Psychiatric medications (continued) Antipsychotics/Mood Stabilizers Seroquel (quetiapine) Zyprexa (olanzepine) Geodon (ziprasidone) Abilify (aripiprazole) Clozaril (clozapine) Haldol (haloperidol) Prolixin (fluphenazine) Other Sedative/Hypnotics Ambien (zolpidem) Sonata (zaleplon) Rozerem (ramelteon) Restoril (temazepam) Desyrel (trazodone) Other ADHD medications Adderall (amphetamine) Concerta (methylphenidate) Ritalin (methylphenidate) Strattera (atomoxetine) Other Antianxiety medications Xanax (alprazolam) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) Tranxene (clorazepate) Buspar (buspirone) Other Your Exercise Level: Do you exercise regularly? How many days a week do you get exercise? How much time each day do you exercise? What kind of exercise do you do? Family Psychiatric History: Has anyone in your family been diagnosed with or treated for: Bipolar disorder Schizophrenia Depression Post-traumatic stress Anxiety Alcohol abuse Anger Other substance abuse Suicide Violence If yes, who had what problems? Has any family member been treated with a psychiatric medication? If yes, who was treated and what medications and how effective was the treatment? Mindful Therapy Group Psychiatric Intake Packet 5
Substance Use: Have you ever been treated for alcohol or drug use or abuse? If yes, for which substances? If yes, where were you treated and when? How many days per week do you drink any alcohol? What is the least number of drinks you will drink in a day? What is the most number of drinks you will drink in a day? In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day? Have you ever felt you ought to cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you ever felt bad or guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? Do you think you may have a problem with alcohol or drug use? Have you used any street drugs in the past 3 months? If yes, which ones? Have you abused prescription medication? If yes, which ones and for how long? _C_ heck if you have ever tried the following: If yes, how long and when did you last use? Methamphetamines Cocaine Stimulants (pills) Heroine LSD or Hallucinogens Marijuana Pain killers/narcotics Methadone Tranquilizers /sleeping pills Alcohol Ecstasy Other How many caffeinated beverages do you drink a day? Coffee Sodas Tea Tobacco History How you ever smoked cigarettes? Currently? How many packs per day on average? How many years? In the past? How many years did you smoke? When did you quit? Pipe, cigars, or chewing tobacco: Currently? In the past? What kind? How often per day on average? How many years? Mindful Therapy Group Psychiatric Intake Packet 6
Family Background and Childhood History: Were you adopted? Where did you grow up? List your siblings and their ages: What was your father s occupation? What was your mother s occupation? Did your parents divorce? If so, how old were you when they divorced? If your parents divorced, who did you live with? Describe your father and your relationship with him : Describe your mother and your relationship with her: How old were you when you left home? Has anyone in your immediate family died? Who and when? Trauma History: Do you have a history of being abused emotionally, sexually, physically or by neglect? Please describe when, where and by whom _ Educational History: Did you attend college? Where? Major? What is your highest educational level or degree attained? Occupational History: Are you currently: Working Not working by choice Unemployed Disabled Retired How long in present position? What is/was your occupation? Where do you work? Have you ever served in the military? If so, what branch and when? Honorable discharge? Other type discharge Relationship History and Current Family: Are you currently: Married Divorced Single Widowed How long? If not married, are you currently in a relationship? If yes, how long? Are you sexually active? How would you identify your sexual orientation? straight/heterosexual lesbian/gay/homosexual bisexual transsexual unsure/questioning asexual other prefer not to answer What is your spouse or significant other s occupation? Describe your relationship with your spouse or significant other: Have you had any prior marriages? If so, how many? How long? Do you have children? If yes, list ages and gender Describe your relationship with your children: List everyone who currently lives with you? Mindful Therapy Group Psychiatric Intake Packet 7
Legal: Have you ever been arrested? Do you have any pending legal problems? Spiritual life Do you belong to a particular religion or spiritual group? If yes, what is the level of your involvement? Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you? more helpful stressful Is there anything else that you would like your psychiatric provider to know? Mindful Therapy Group Psychiatric Intake Packet 8
Mindful Therapy Group Frequently Asked Questions and Office Policies Distinguishing between an emergency, urgent, and non-urgent request: In the event of an emergency (you feel suicidal, homicidal, or have a medical emergency) you should call 911 or go to the closest emergency room. If you have an urgent need for consultation (medication side-effects, increase in symptoms, etc.) you should call the main office number 206-319-4446 extension 1 and let our administrative staff know it is an urgent request. After hours and on weekends if you have an urgent request you should call the crisis clinic 1-866-4- CRISIS (1-866-437-4747), and please leave a message on your provider s extension as well as your therapist s extension using the directory at 206-319-4446. Please note: Most clinical issues should be shared in your session with your provider. If calls and case management become excessive, we will need to charge for case management time, at our rate of $200/ hour. We will always inform you prior to providing this service and prior to billing for it. Many issues including insurance or billing questions, appointment changes, medication questions or medication refills can be resolved during normal business hours, Monday through Friday 8 am 7 pm, and will be handled by our administrative team. Financial Policies: All payments are expected at the time of service: Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable co-insurance, co-payments, and deductibles for participating insurance companies. We accept cash, personal checks, and credit cards. Insurance: We bill participating insurance companies as a courtesy to you. You are expected to pay your deductibles and co- payments at the time of services. If we have not received payment from your insurance company, you will be expected to pay the balance in full. You are responsible for all charges. We are currently accepting Regence BC/BS, Premera Blue Cross, Group Health, and First Choice Network plans, and can bill out-of-network for all other plans. Please provide full insurance information and your insurance card upon your initial visit to determine eligibility of benefits, and obtain authorization from your insurance provider when necessary prior to your first visit. If your insurance plan requires pre-authorization for services, it is ultimately the responsibility of the client to obtain this authorization prior to being seen by your provider. If you fail to obtain authorization, any and all charges incurred and not reimbursed, will be your financial responsibility. We reserve the right to bill our standard fees for case coordination, clinical and legal write-ups, and phone consultations exceeding 5 minutes per week. Our time is valuable and is best served providing high quality care to you while you are here in session. There is no charge for routine telephone calls to our administrative staff regarding scheduling, appointments, or billing. Outstanding Balance: If an unpaid balance remains after 60 days, we will require a payment plan be initiated to continue to provide services. Unpaid balances that exceed 90 days will initiate a collection effort by our administrative team, and after 120 days will be sent to an outside collections agency for recovery and some identifying confidential information will be released in this process. This may negatively impact your credit. We realize that people have financial difficulty, so please communicate with our office staff so that they may assist to create a financial plan with you. Billing questions: If you should need any assistance or have billing questions, please call the office during business hours and Mindful Therapy Group Psychiatric Intake Packet 9
speak with our administrative staff. Dismissal/Termination of care: It is your right to terminate your relationship with us for any reason. We will terminate our relationship with you in a few specific cases including being rude to staff, missing your appointments, abusing medications prescribed to you, not following up on your therapeutic plan, etc. Missed Appointments/ Untimely Cancellations: Missed appointments represent a cost to us, but more importantly it is a disservice to other patients who could have been seen in the time set aside for you. If you are unable to keep your appointment, please give 48 hours notice so we can fill the appointment with another patient. Please note that if less than 24 hours notice is provided, you will be billed a missed appointment fee. A missed appointment charge is not a professional service charge and is not covered by your insurance. We, therefore, will charge you a full reimbursement rate for ALL and ANY missed appointments. Initial: A fee of $200 will be charged to your account for appointments cancelled within less than 24 hours notice. Excessive abuse of scheduled appointments will result in discharge from practice. Initial: If you are ill and cannot make your appointment, a doctor s note may be requested to waive any charges. If you arrive for your appointment late, please be aware that there is the possibility that your appointment may need to be rescheduled, as to not inconvenience the next scheduled patient. Complaints: You have a right to have your complaints heard and resolved in a timely manner. If you have a complaint about your treatment, your physician, therapist, or any office policy please inform us immediately and discuss the situation. If you do not feel the complaint has been resolved, you may also inform your insurance carrier and file a complaint if you choose. Prescriptions: Medication prescriptions should be written during sessions with your psychiatric nurse practitioner. This allows them to discuss how they are working and how long you should take them. Very occasionally, you may need a refill between sessions. Please call your pharmacy as soon as possible if this should happen to you. Keep an eye on your dosage amount to avoid a rush, and to give the pharmacy and doctors enough time to get your refill processed. Please allow SEVEN BUSINESS DAYS for the office staff to check against your records and acquire clinician approval. We will not authorize refills if you have no future appointment, since we are legally required to ensure that you are in active treatment if we prescribe medications. Please note that in the event of a missed, rescheduled, or cancelled appointment, you medications may not be refilled. We are unable to provide refills of medications provided by other doctors or for other medical conditions, including narcotic pain medications, and may not prescribe any medications on your first visit. Certain medicines (primarily medications used for Attention Deficit Disorder) cannot be refilled by phone or fax. A paper (hard copy) prescription should be requested by phone to our office at 206-319-4446. If the refill is approved, office staff will contact you to find out when you wish to pick up your prescription at the office. Consent for Treatment I hereby authorize Mindful Therapy Group to render mental health services to me. I have read and understand these policies and have received a copy for myself. Signed: Printed Name: Date: Responsible Party for minors under the age of 13: Signature: Mindful Therapy Group Psychiatric Intake Packet 10
Date: Printed Name: Relationship: HIPAA Date: I acknowledge that I have received the Notice of Privacy Practices explaining HIPAA. Signed: Printed Name: Financial Responsibility I authorize provider to release information to insurance carrier(s) listed and be paid directly by insurance carrier(s) for services billed. I acknowledge that I am responsible for all charges not paid by my insurance companies including: copays, coinsurance, deductibles, insurance plan refusal to pay for failure to obtain authorization, and missed and late cancellation fees. If it becomes necessary to effect collections of any amount owned, the undersigned agrees to pay all costs and expenses, including reasonable attorney fees. Signature: Date: Signature of Responsible Party: Date: Mindful Therapy Group Psychiatric Intake Packet 11