Initial Intake Form

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

Your Name (required)

Date of Birth

Email (required)

Brief reason for initial consult (required)

Communication Preference (required)

Emergency Contact Name (required)

Emergency Contact's Phone Number (required)

Referred By

Medication List (required)

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

Medical Issues (required)

If none, write "none".

Release of Information (required)

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

Policy Review

1. I have read and understand policies regarding fees and financial arrangements. 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 an insurance plan, 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.

2. I have read and understand policies regarding cancellations/missed appointments. 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 am responsible for the provider’s full out-of-pocket fee, even if I use insurance.

3. 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.

Credit Card Authorization for Austin PsychCare

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)

Sign Here: