INTAKE FORM

First Name

Last Name

Address

Home Phone

Cell Phone

Patient Birthday

Patient SS#

Sex

Male

Female

Marital Status

Single

Married

Others

Patient Employer Name

Employee Adress(city, state, zipcode)

Employer Phone

INSURED/RESPONSIBLE PARTY INFORMATION | RELATION TO PATIENT:

First & Last Name

Adress(If different from patient)

Phone

SS#

Patient Birthday

Employer

INSURANCE INFORMATION

Primary Insurance Name

Adress(street, city, state, zipcode)

Phone

Group Number

ID Number

Employer

Employer Phone

Secondary Insurance Name

Adress(street, city, state, zipcode)

Phone

Group Number

ID Number

Employer

Employer Phone

Primary Care Provider

Referring Provider

Referring Provider Phone

In Case of Emergency Contact

Relationship

Phone Number

ASSIGNMENT AND RELEASE: I hereby authorize my insurance benefits be paid directly to the provider and I am financially responsible for non-covered services. I also authorize the provider to release any information required in the processing of this claim and all future claims. If my account is sent to a collection agency, I agree to pay all collection and attorney fees.

SIGNATURE (Patient or if minor Signature of parent or guardian)

Date

Authorization to release health information to:

Full Name

Adress(street, city, state, zipcode)

Phone

Date of Service

Never Date:

Release the following Information

All Records

Chart Notes

AUTHORIZATION EXPIRES (UNLESS OTHERWISE NOTED THIS AUTHORIZATION WILL REMAIN IN EFFECT ONE YEAR FROM THE DATE SIGNED)

RELEASE INFORMATION

● once “this facility” discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information.

● I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR (164.524).

● my records are protected and cannot be disclosed without written permission this Authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Record Department.

Signature of Patient or Legal Representaive

Date

If signed by Legal Representative, Relationship to Patient

Signature of Witness (optional)

MEDICAL HISTORY

Briefly state the reason why you would like to see a Psychiatrist

Primary Care Physician

Psychiatrist/Therapist

How did you hear about us

Have you ever had a head injury?

Facility

Phone Number

Please provide information regarding current medications- Psychiatric and non-psychiatrist

Have you ever had Seizures?

Do you have any medication allergies?

Previous Psychiatric Medication Tried. (Dosage and reason for stopping)

Previous Psychiatric diagnosis

Family History of Psychiatric Disorder?

Any History of Abuse or Trauma

Any thoughs to hurt yourself or others?

CONSENT TO USE THE TELEHEALTH BY CareCloud Live with my Provider

CareCloud Live is the technology service we use to conduct Tele-health videoconferencing appointments. It is simple to use and there are no passwords required to log in. I understand I will receive a link by email or text message, depending on my preference. By signing this document, I acknowledge:

Tele-health by CareCloud Live is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911. Though my provider and I may be in direct virtual contact through the Telehealth Service, neither CareCloud Live nor the Tele-health Service itself provides any medical or healthcare services or advice for emergency or urgent medical services.

The Tele-health by CareCloud Live facilitates the videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care. I understand that technical difficulties may arise as times that require external technical support to resolve and may require rescheduling of my telehealth visit.

To maintain confidentiality, I will not share my Tele-health appointment link with anyone unauthorized to attend the appointment. By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me and that I fully Understand its content, including the risks and benefits of Telehealth Services; That I have been given the opportunity to ask questions and that any questions have been answered to my satisfaction.

choce one

Spouse

Parent

Gaudian

I understand the concepts and conditions of informed consents, privacy and confidentiality. I understand that I have the opportunity to discuss these concepts and conditions and to ask for clarification of parts which I am concerned about or do not fully understand.

I understand that I will be informed of the goals, expectations, procedures, benefits, and possible risks involved in the evaluation and treatment/therapy. When using telemedicine services, technical issues could affect a session if there is a poor connection or non-functioning equipment.

I understand that all communication will be private, legally privileged, and confidential unless otherwise specified by the specific laws presented below or unless I provide my written consent with a specified release of information

I also understand that there are no guarantees of positive outcome for the treatment/therapy. If I have health insurance, I understand that I am responsible for confirming coverage and network status before I receive treatment and that I am responsible for payment when services are not covered by my plan.

I understand that applicable payment is due at the time-of-service which includes co-pays, balances due on past services according to my health plan coverage, and self-pay service.

I understand that I may ask questions by secure message within the CareCloud portal anytime. I understand that I am responsible for privacy related to the technologies that I use to connect with my provider and that I must password-protect those technologies to increase the security information

I understand that I may be immediately discharged if my behavior is a threat to my provider(s) or the property of my provider’s organization.

Upon such discharge, I understand that I will be given a list of alternate providers in my area from which I may choose a new provider for the continuation of my psychiatric care. I understand I am free to choose another provider that is not on the referral list and that I am responsible for making appointments immediately to prevent gaps in my care.

INFORMED CONSENT TO RECEIVE PSYCHIATRIC TREATMENT

Patients taking DEA controlled substances such as ADHD stimulants or benzodiazepines, may need to provide documentation of previous diagnosis before medications will be prescribed.

These medications will also require a separate treatment agreement.

ACKNOLWEDGEMENT:

In signing my name below, I acknowledge that I am giving my informed consent to receive psychiatric treatment at KNK Mental Health Services. Psychiatric treatment consists of diagnostic services and medication management.

While therapy is almost always a good idea for everyone, please note KNK Mental Health Services is a medication-based service. Should I desire therapy or am not considering psychiatric medications, I will refer to therapist

I agree that this consent form may be electronically signed and that my electronic signature appearing on this consent form is the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. I understand that I may opt-out of signing this document electronically by contacting the Student Health Center.

Your Signature

Date

Print Name

Date

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INTAKE FORM

KNK Mental Health Services LLC