Behavioral-Health-Intake-Form - GetWell Health System

Authorizations:
Release of Information to Insurance Company (Please check that you understand):*

I hereby authorize the release to my insurance company of any information required in the course of my examination or treatment. This information may be released now or in the future.I hereby assign to GetWell Health System (GWHS) any and all rights, title, and interest that I have in any insurance proceeds or benefits payable to me or on my behalf for services rendered to me by GWHS, whether services are considered in-or out-of-network.I authorize and direct my insurance carrier and/or health care plan to make payment of any and all such amounts directly to GWHS, rather than myself or any other insured.I understand that I am financially responsible to GWHS for all charges, including those not paid by insurers or health care plans for services not authorized as specified ified in my benefit package, incurred by me or in my behalf.
Authorization for Medical Treatment (Please check that you understand):*

I hereby authorize the physicians, nursing staff, and allied health professional staff (assisted by the employees of GetWell Health System to provide medical treatment to me or the above named patient.I agree to diagnostic tests and procedures, including x-rays, CT, and the administration/injection of pharmaceutical products and medication in addition to the drawing of blood.I understand and authorize the administration of pharmaceutical agents and medications.I acknowledge that no guarantees or assurances have been made to me concerning the results or findings intended from treatment or examination at GetWell Health System
Power of Attorney

I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect the care I receive from the provider, my eligibility for benefits, or enrollment, payment, or coverage of these services.
Patient Name*
Signature*

Clear
Date*

MonthDayYear
Date
If applicable, legal representatives sign below: By signing this form, I acknowledge that I am the legal representative of the member identified above and will provide written proof (e.g. Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the member's behalf with respect to this authorization form.
Printed Name of Legal Representative
Signature of Legal Representative

Clear
Date

MonthDayYear
Date

Controlled Substance Prescription Contract

Controlled substances are medications that have some potential for abuse or dependence. If not used properly they casesuse serious medical problems and if sold for street use they contribute to addiction and crime. Get Well Health System MUST mirage these medications in ways that are medically appropriate and comply with all Federal and State regulations. Please read the following carefully.

By signing, you agree to follow every stipulation of the contract. Exceptions cannot be made,
- Controlled substances are habit-forming and can cause physical dependence. Suddenly stopping the medication may cause physical withdrawal symptoms. These symptoms may include flu-like feelings, crawling skin, sleeplessness, irritability, anxiety, and even seizures. I understand that I may develop physical dependence from medications.
- Patients with a history of substance abuse, including alcoholism, are at high risk of relapse from certain medications. Patients with a strong family history of substance abuse are also at a high risk for addiction. I understand and agree that I have notified North Clark Medical Group of any personal or family history of substance abuse, including alcohol abuse.
- I understand that my medications may not be taken more often than prescribed. If you medication is not controlling your symptoms, you must schedule a follow up appointment. You cannot increase your dose. Prescription refills will not be given early under any circumstance. Travel plans during your regular refill appointment time will not result in early refills so please plan accordingly. I understand that if I run out of my medication, I may suffer withdrawal symptoms.
- Obtaining controlled medications from more than one doctor without notifying all physicians who prescribe to you is a felony. The only exception is medication taken during an inpatient hospitalization. You must immediately notify us during your next appointment if you receive pain medications, sleeping pills, tranquilizers, or other controlled medications from any other provider (including emergency room doctors). I understand that I will be dismissed from the practice if I do not notify North Clark Medical Group that I have received controlled medications from another source.
- Patients are responsible for scheduling and keeping all appointments. I understand that to get refills, I must be seen in the office and that no refills or medication changes will be made after hours or on the weekends.
- I understand that I am receiving medications that are at a high risk of being stolen. I am responsible for protecting these medications and understand that North Clark Medical Group cannot replace medications that are lost, stolen, or damaged. We also recommend that you file a theft report with local law enforcement agencies.
- I understand that selling, trading, or giving my medications to anyone is illegal.
- I understand that it is the policy of North Clark Medical Group to perform urine or serum drug test during office visits and randomly at will. I understand that if I refuse or fail to provide a urine sample, I will not be prescribed my controlled medications. I also understand that should North Clark Medical Group become aware during testing that I am using street or prescription drugs not prescribed to me that it will result in loss of medical treatment with a controlled substance.
- I understand that it is the policy of North Clark Medical Group to perform random pill counts. I will maintain an active phone number as well as answer and return any missed calls from North Clark Medical Group immediately. I will notify the office within 24 hours with any changes to my phone number. When called in for a pill count, I understand that I have 24 hours to arrive to the office with my medication in the original pharmacy container with the label intact. Failure to return multiple calls from our office, maintain an active number where you can be reached, or to appear for pill counts will result in loss of medical treatment with a controlled substance.
- I understand that changing the date, quantity, or strength of a medication or altering a prescription in any way is illegal. This includes forging a prescription or provider signature. Our office cooperates fully with local law enforcement and the DEA. Any violation to these laws will result in immediate dismissal from the practice and may be reported to the authorities and local pharmacies.
- I understand that my provider will use his or her medical judgment when deciding what medications to prescribe for my medical care and he or she may choose at any time to change medications, reduce dosage, or stop prescribing a controlled substance if he or she believes it is medically appropriate. Additionally, if I violate this contract, North Clark Medical Group must consider that I may be abusing or selling medications. IN such instances, doctor-patient confidentiality does not prevent North Clark Medical Group from providing pertinent information to law enforcement agencies.
Patient Name*
Signature*

Clear
Date*

MonthDayYear
Date

HIPAA Release of Information Authorization Form

North Clark Medical Group herein know as NCMG
I hereby authorize NCMG and its affiliates, employees, and agents to release information to:*

SpouseFamilyOtherInformation is NOT to be released to anyone.
My or my legal dependents person health information is maintained by NCMG (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided and which identifies me or my legal dependents name, address, social security numbers, and member ID number) except the following information:
For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if NCMG, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.
Patient Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Authorization for Release of Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released prior to the written revocation. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to consent under my policy. Unless otherwise revoked, this authorization will expire on the below date. If I fail to provide an expiration date, this authorization will expire in 60 days from date of signature.*

MonthDayYear
Date
For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if NCMG, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.
Patient Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

	Check if Yes	Type of Exercises
At least 3X per Week

	Yes	No
If you checked yes to more than one of the above, have several of these ever happened during the same period of time?

	Yes	No
I have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had mental depressive illness or bipolar disorder?

	Yes	No
Has a health professional ever told you than you have manic-depressive illness or bipolar disorder?

Patient Health Questionnaire and General Anxiety Disorder (PHQ-9 and GAD-7)
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Depression PHQ

Over the last 2 weeks, how often have you been bothered by any of the following problems? Select Your answers. Rate from 0 to 3 as per heading.

	If Not at All Put 0	If Several Days Put 1	If Over half the days Put 2	If Nearly everyday put 3
Little Interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are failure or have let yourself or your family down.
Trouble concentrating on things, such as reading the newspaper or watching television.
Moving or speaking so slowly that other people could have noticed. Or the opposite - being fidgety or restless that you have been moving around a lot more than usual.
Thoughts that you would be better off dead, or of hurting your self in some way.

Total Score from above table*
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not Difficult at allSomewhat difficultVery DifficultExtremely Difficult
Anxiety Questionnaire
Over the last 2 weeks, how often have you been bothered by any of the following problems? Rate from 0 to 3 as per heading.

	If Not at All Put 0	If Several Days Put 1	If Over half the days Put 2	If Nearly everyday put 3
Feeling nervous, anxious, or on edge.
Not being able to stop or control worrying.
Worrying too much about different things.
Trouble relaxing.
Being so restless that Its hard to sit still.
Becoming easily annoyed or irritable.
Feeling afraid as if something awful might happen

Total Score from above table*

Telehealth Appointment Policy

This policy provides guidelines for telehealth appointments for psychiatric patients. It is designed to ensure that patients receive efficient, effective, and secure psychiatric care while leveraging the convenience of telehealth technology.

1. Scheduling Appointments

Patients can schedule telehealth appointments by calling our office. Patients should provide any necessary information during scheduling, including the reason for the appointment and any symptons they are experiencing.

2. Technology Requirements!

Patients must have access to a device with a-camera, microphone, and internet connection. Prior tothe appointment, patients should test their device to ensure it meets the requirements for a telehealth session

3. Privacy and Confidentiality

All telehealth appointments will be conducted in a private, HIPAA-compliant virtual environment. Both the provider and patient should ensure they are in a private location during the appointment to prolet patient confidentiality.

4. Appointment Protocol

A link will be sent to the patient when the provider is ready to see the patient, the link is active for 15 minutes. At the start of each appointment, the provider will verify the patient's identity and location. The patient cannot be in a moving vehicle or driving during the appointment for safety reasons. The patient must be in a secure area without anyone else present.

5. Prescriptions

If a prescription is necessary, it will be sent electronically to the patient's pharmacy of choice. Controlled substances may have additional restrictions and may require in-person appointments.

By utilizing our telehealth services, patients agree to abide by the terms and conditions outlined in this policy.
Telehealth Session Policy for Holly Woosley, APRN, PMHNP

We are committed to providing the best possible care to all our patients. As part of our ongoing efforts to make healthcare more accessible and convenient, we offer telehealth sessions as an alternative to In-office visits for many patient populations.

However, in order to ensure the effectiveness and continuity policy regarding missed telehealth sessions

Missed Telehealth Sessions Policy

İf a patient misses two scheduled telehealth sessions without prior notification, they will be required to switch to in-office visits only. This policy is în place to ensure that we are able to provide consistent and high-quality care to all our patients.

Procedure for Missed Sessions

1. After the first missed telehealth session, we will contact you to reschedule and remind you of our policy.

2. If a second telehealth session is missed, we will again attempt to contact you. If we are unable to reach you or if you do not reschedule, your care will automatically switch to in-office visits only.

This policy is designed to ensure that all our patients receive the care they need in a timely manner. We understand that unexpected circumstances can arise. If you are unable to attend a scheduled telehealth session, please notify us at least 24 hours in advance so that we can reschedule your appointment.

By signing below, you acknowledge that you have read, understood, and agreed to this policy.
Patient Name

First NameLast Name
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

	Cigarettes	Cigars	Pipe
# Packs/Day
# Years Smokes Quit?
When Stopped?

	Check if Yes	How many Drinks
Rarely
Occasionally
Moderately
Daily

	Check if Yes	How many per Day
Coffee
Soda
Tea
Other Products

	Name	Dosage	How taken	When Started/Stopped?
1
2
3
4
5

	Yes	No
...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 you didn't really miss it?
...you were much more talkative or spoke much faster than usual?
...thoughts race through your head, or you couldn't slow your mind down?
...you were so easily climacteric 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 into trouble?

Behavioral Health

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Advanced Diagnostics

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Cardiology

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New Patient Packet

Contact Information

Insurance Information :

Authorizations:

Power of Attorney

Controlled Substance Prescription Contract

HIPAA Release of Information Authorization Form

Authorization for Release of Information

Symptoms Check (✔) symptoms you currently have or have had in the past

Habits

THE MOOD DISORDER QUESTIONNAIRE

Patient Health Questionnaire and General Anxiety Disorder (PHQ-9 and GAD-7)

Depression PHQ

Anxiety Questionnaire

Adverse Childhood Experience Questionnaire for Adults

Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Mental Health Care

Primary & Urgent Care

Advanced Diagnostics

Pain Management

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