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? *

Other Health Insurance

Do you have TRICARE? *
Do you have other health insurance (OHI)? *
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 Medicare? *
Do you have Tricare for Life? *
Do you have another insurance? *
Do you have another insurance? *
Do you have another insurance? *

I do not have OHI. *

Adult Intake Form

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Gender *
Would you like to add another contact number? *
Best time to call *
Emergency contact information
 NamePhone numberRelationship
1
2

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. *
Is financial responsibility someone other than the patient? *
Visa
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. *

Referral Information

Presenting Problem

Are you being scheduled for TMS? *

TMS Screening Tools

You must read the consent form before proceeding. By checking this box, you acknowledge that you have read the TMS Consent for Treatment. *
TMS Screening Questionnaire *
 NoYes
Have you ever had an adverse reaction to TMS?
Have you ever had a seizure?
Have you ever had an EEG
Have you ever had a stroke?
Have you ever had a head injury (include neurosurgery)?
Do you have an metal in your head?
Do you have any implanted devices such as cardiac pacemakers, medical pumps, or intracardiac lines?
Do you suffer from severe headaches?
Have you ever had any other brain-related condition?
Have you ever had any illness that caused brain injury?
Are you taking any medications?
If you are a woman of childbearing age, are you sexually active, and if so, are you using a reliable method of birth control?
Does anyone in your family have epilepsy?
Do you need further explanation of TMS and its associated risk?
PHQ-9 *
 Not at allSeveral daysMore than half the daysNearly every day
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 a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching TV
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
Thoughts that you would be better off dead or of hurting yourself in some way
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? *

Medication History

 *
 MedicationDosageDurationResponse (please note if discontinued due to side effects)
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6

Treatment History

Prior OUTPATIENT psychotherapy? *
Dates if known.
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Therapist information
 NameCity, StatePhone number
1
2
3
4
5
Treatment Modality (check all that apply)
 
Has any family member had any mental health treatment? *

Notices

By checking this box, you acknowledge that you have read the notices above. *
I have read the financial agreement. *
I have read the no-show policy. *

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. *
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