Medicaid Statement

Please note that we are NOT a Medicaid provider. By clicking the box below you are acknowledging that you DO NOT have Medicaid as either a primary OR secondary insurance.

Do you have Medicaid? *

NO

Payment Type

Will you be using insurance? *

Yes

No

Please ensure you have discussed the self-pay rates with our intake department as they may have changed.

Health Insurance

Do you have Medicare? *

YES

NO

Do you have TRICARE? *

YES

NO

Are you the sponsor? *

Yes

No

Sponsor First Name *

Middle Initial

Sponsor Last Name *

Sponsor SSN *

Sponsor Date of birth * +

TRICARE is secondary to all other insurances and will not pay if we are not in network with your OHI provider. This will result in the Responsible Party receiving a bill for services regardless if you have TRICARE or not. Please confirm you do not have OHI.

Do you have other health insurance (OHI)? *

YES

NO

Do you have Tricare for Life? *

YES

NO

Select your insurance below. If you do not see your insurance listed, please contact our office as we may not be in network with your insurance company. *

Do you have another insurance? *

Yes

No

Select your insurance below. If you do not see your insurance listed, please contact our office as we may not be in network with your insurance company. *

Do you have another insurance? *

Yes

No

Select your insurance below. If you do not see your insurance listed, please contact our office as we may not be in network with your insurance company. *

Do you have another insurance? *

Yes

No

Select your insurance below. If you do not see your insurance listed, please contact our office as we may not be in network with your insurance company. *

Please upload a copy of the front and back of your commercial insurance card. Do not upload any military ID cards. *

I do not have OHI. *

-

Adult Intake Form

First Name *

Middle Initial

Last Name *

Patient SSN *

Sponsor or Subscriber SSN *

Date of birth * +

Age *

Gender *

Male

Female

Street Address *

Address Line 2

City *

State *

Zip Code *

What is the preferred number to reach you at? *

Phone Number *

Would you like to add another contact number? *

Yes

No

Phone Number

Best time to call *

7:30 - 9:00

9:00 - 12:00

12:00 - 3:00

3:00 - 5:00

Email Address *

Emergency contact information

	Name	Phone number	Relationship
1	Name	Phone number	Relationship
2	Name	Phone number	Relationship

Responsible Financial Party

We require a credit card to be placed on file. Cards are securely filed and will be used only for payment of co-pays, co-insurance, payments for service and no-show fees. Credit card information must be entered even if you are not the responsible party.

TRICARE Prime and Active Duty Service Member will not be charged a co-pay but must still put card information for any no-show fees.

In order for us to verify the credit card information, we will run a $.01 transaction and then immediately void this transaction. By checking the box below, you agree that we may charge the card for this transaction. *

I agree

Is financial responsibility someone other than the patient? *

Yes

No

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Security Code *

By checking the box below, you agree that we may charge the card provided for the amount owed the day after it is reflected on the account. *

I agree

First Name *

Last Name *

Street Address

Address Line 2

City

State

Zip Code

Home Phone Number

Work Phone Number

Cell Phone Number *

Email address *

Referral Information

Who referred you to Family Care Center? *

Name and number of your primary care physician if known?

Name and number of therapist if known?

Presenting Problem

What are the problems or concerns you are having? *

When did the problem begin and for how long has it gone on? *

Are you being scheduled for TMS? *

Yes

No

TMS Screening Tools

TMS Consent Form

You must read the consent form before proceeding. By checking this box, you acknowledge that you have read the TMS Consent for Treatment. *

Agree

TMS Screening Questionnaire *

	No	Yes
Have you ever had an adverse reaction to TMS?	No	Yes
Have you ever had a seizure?	No	Yes
Have you ever had an EEG	No	Yes
Have you ever had a stroke?	No	Yes
Have you ever had a head injury (include neurosurgery)?	No	Yes
Do you have an metal in your head?	No	Yes
Do you have any implanted devices such as cardiac pacemakers, medical pumps, or intracardiac lines?	No	Yes
Do you suffer from severe headaches?	No	Yes
Have you ever had any other brain-related condition?	No	Yes
Have you ever had any illness that caused brain injury?	No	Yes
Are you taking any medications?	No	Yes
If you are a woman of childbearing age, are you sexually active, and if so, are you using a reliable method of birth control?	No	Yes
Does anyone in your family have epilepsy?	No	Yes
Do you need further explanation of TMS and its associated risk?	No	Yes

PHQ-9 *

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things	Not at all	Several days	More than half the days	Nearly every day
Feeling down, depressed, or hopeless	Not at all	Several days	More than half the days	Nearly every day
Trouble falling or staying asleep, or sleeping too much	Not at all	Several days	More than half the days	Nearly every day
Feeling tired or having little energy	Not at all	Several days	More than half the days	Nearly every day
Poor appetite or overeating	Not at all	Several days	More than half the days	Nearly every day
Feeling bad about yourself, or that you are a failure or have let yourself or your family down	Not at all	Several days	More than half the days	Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching TV	Not at all	Several days	More than half the days	Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual	Not at all	Several days	More than half the days	Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way	Not at all	Several days	More than half the days	Nearly every day

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

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Medication History

*

	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 1	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 2	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 3	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 4	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 5	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 6	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)

Treatment History

Prior OUTPATIENT psychotherapy? *

Yes

No

How many times?

Dates if known.

+-

Diagnosis *

Therapist information

	Name	City, State	Phone number
1	Name	City, State	Phone number
2	Name	City, State	Phone number
3	Name	City, State	Phone number
4	Name	City, State	Phone number
5	Name	City, State	Phone number

Treatment Modality (check all that apply)

Which, if any, were beneficial?

Has any family member had any mental health treatment? *

Yes

No

Who and for what reason or diagnosis and where they given any medications? (list all here)

Notices

Family Care Center Notices

By checking this box, you acknowledge that you have read the notices. *

Agree

I have read the financial agreement. *

Yes

I have read the no-show policy. *

Yes

Acknowledgement and Signature

By signing this form, you agree that you are willing to be seen by a provider at the Family Care Center and will become a client of this clinic upon submission of this form. Clients are responsible for all payments at time of service. Clients who do not show up for their initial medication appointment are subject to a $100 no-show fee. Furthermore, clients who miss a follow-up appointment for medications are subject to a $100 no-show fee. Clients are also charged a $50 no-show fee for missed therapy appointments. These fees must be paid prior to any further appointments being made. Two or more no-shows for an initial appointment can result in you not being accepted as a client. *

clear

Cognitive Processing Therapy	Cognitive Behavioral Therapy
EMDR	Prolonged Exposure
Dialectical Behavioral Therapy	Not Known
Other Other