Patient Application for Medication Management

Personal Information:

Full Name *

Date of birth (please use a dash to seperate MM-DD-YYYY) *

Address

Email *

Phone Number *

Emergency Contact Name and Number:

Primary Care Provider Contact Name:

Primary Care Provider Contact Number:

Do you currently see a psychiatrist or psychiatric nurse practitioner that has referred you for our services?

Yes

No

Out of professional courtesy, we are not able to provide medication management if you were referred by a psychiatrist or psychiatric nurse practitioner unless we have your provider’s consent to transfer your care.

Psychiatric History:

If others, please specify:

2. List any current or past psychiatric medications you’ve taken, including the duration and effectiveness:

Medication 1
Medication 2
Medication 3
Medication 4
Additional Medication

3. Have you ever received any of the following treatments?

Psychotherapy (including talk therapy, CBT, DBT, EMDR, etc.)

TMS (Transcranial Magnetic Stimulation)

ECT (Electroconvulsive Therapy)

Ketamine Therapy

Spravato Therapy

If others, please specify:

4. Do you have any of the following medical conditions?

High Blood Pressure

Heart Disease

Liver or Kidney Disease

If others, please specify:

5. List all current medications (including over-the-counter and herbal supplements):

Psychiatric Symptoms:

6. Describe your current mood and symptoms (e.g., sadness, loss of interest, sleep disturbances):

7. Have you had thoughts of harming yourself or others in the past month?

Yes

No

8. Any history of self-harm or suicide attempts?

Yes

No

Telehealth Suitability:

9. Do you have access to a quiet, private space for telehealth sessions?

Yes

No

10. Do you have good internet reliability for video calls?

Yes

No

11. Do you have experience with telehealth or video conferencing platforms?

Yes

No

Treatment Goals and Expectations:

12. What are your primary goals for seeking treatment?

13. Are you specifically interested in exploring treatments like Spravato, Ketamine, or TMS?

Yes

No

Insurance and Payment:

14. Are you willing and able to cover out-of-pocket costs if insurance does not cover certain treatments or medications?

Yes

No

Consent and Understanding:

I understand that this telehealth practice might recommend in-person treatments at our clinic located in Winter Garden or Kissimmee if deemed necessary by my provider.

Yes

No

I consent to the sharing of my medical information between this telehealth practice and the in-person treatment facilities at Revitalizing Infusion Therapies .

Yes

No

Please Upload a Front and Back Picture of Your Insurance Card *

Please Upload a Front and Back Picture of Your Insurance Card

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