Initial Intake Form

Prior to your initial appointment, please fill out all sections and then hit
SUBMIT INITIAL INTAKE button.

Your Name

Date of birth

YYYY

Brief reason for initial consult

If you are seeking treatment for ADHD, please note the you will not receive a stimulant (i.e. Ritalin, Adderall, Vyvanse) on your first visit without a documented professional diagnosis or without formal neuropsychiatric testing to confirm the diagnosis.

Communication Preference

Emergency Contact

Emergency Contact's Phone Number

(###)

###

####

Referred By (person's name or where you found us)

Medication List

Please list all medication, doses, and prescribing instructions (e.g., Aspirin, 81 mg, once a day) If none, write "none"

Medical Issues

Please list any medical issues or previous surgeries (e.g., diabetes, high blood pressure) If none, write "none"

Release of Information

If you would like us to collaborate with other providers/loved ones, please go to our Release of Information page and fill out the form; this gives us permission to contact them.

Anything else you'd like us to know that may help us with your care?

Please check all of the following:

I have reviewed and understand the Office Policies and Notice of Privacy Practices (first link under 'Patient Forms').

I understand that I must keep an active credit card/HSA/FSA card on file. I am responsible for updating this card when appropriate. If I’m a self-pay patient, I understand that my card will be automatically charged after appointments. If I'm using BCBS PPO, United Behavioral Health PPO, or Seton Insurance, I am aware that Austin PsychCare will submit the claim, and that I am financially responsible for whatever insurance does not cover (i.e., copays, deductibles, inactive insurance policies, policy exclusions for mental health, HMO plans). I understand that my chosen payment method will be automatically charged. I am aware the Austin PsychCare does not accept any Medicare/Medicaid insurance plans.

I have read and understand policies regarding fees and financial arrangements.

I understand that appointment cancellations require 24 hours’ notice via phone during normal business hours. Monday cancellations must occur before noon the previous Friday. I understand that the office does not accept cancellation requests via e-mail or weekend voicemails. If I do not follow the cancellation policies, I understand that I am responsible for the provider’s full out-of-pocket fee, even if I use insurance.

I have read and understand policies regarding cancellations/missed appointments

I understand that if I'm seeking a new ADHD diagnosis, I will need formal neuropsychiatric testing to confirm the diagnosis. I understand that Austin PsychCare does not prescribe controlled substances such as benzodiazepines (Xanax, Klonopin) or stimulants (Adderall, Ritalin) at the first few visits.

I have read and understand policies regarding a new ADHD diagnosis and controlled substances

Credit Card Authorization

I authorize the use of my credit card on file for the charges related to services provided by Austin PsychCare. I understand that the amount charged to my credit card will be reflected on my credit card statement within seven days of authorization. The amount charged is based on services requested by me.

Electronic Signature (I have accepted the terms above)

Today's Date

YYYY

Initial Intake Form

Prior to your initial appointment, please fill out all sections and then hit SUBMIT INITIAL INTAKE button.

Prior to your initial appointment, please fill out all sections and then hit
SUBMIT INITIAL INTAKE button.