EMERGENCY CONTACT

Emergency Contact Name

Contact phone number

Address

Patient's Relation

PHARMACY DETAILS

Pharmacy details- Name and Address

Allergies

INSURENCE CHECK

Insurance check box *

INSURENCE DETAIL

Active Primary Insurance

Policy ID

Group ID

Policy Holder's Name

Relation to Patient

Details of any secondary insurance

Please upload picture of your insurance card Insurance card Front And back

CLINIC POLICIES

*Our office Does not do FMLA

**48 hours( Excluding Weekends) cancellation is required to avoid No Show fee

I Agreed and Acknowledge to Treatment Consent and Financial Policy

I Agreed and Acknowledge to HIPAA Notice of Privacy Practices

I Agreed and Acknowledge to Informed Consent For Telepsychiatry

I hereby acknowledge that the Clinic Policies have been made available to me for review. I am aware that the policies for this practice may change from time to time and that the current copy of the policy is always available upon request from the GHHP staff. I understand that the clinic is not responsible for providing me with the updated policy and it is my responsibility to request GHHP staff in writing. As you are filling this form electronically, typing your name in this field will be equivalent to signing your name on a paper document.

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CREDIT CARD AGREEMENT FORM

Credit Card Account Type

Card Holder's Name
Card Number
Expiration date
CVV
Billing Address
Billing Zip Code
Name of the Person Covered by this Card

By signing below , I authorize Greater Height Holistic Psychiatry PLLC to keep my signature and my credit card information securely on-file in my account. I authorize Greater Heights Holistic Psychiatry PLLC to charge my credit card for any agreed upon payments. I have reviewed the updated financial policy of Greater Heights Holistic Psychiatry PLLC. If the credit card that I give today changes, expires, or is denied for any reason, I agree to immediately give Greater Heights Holistic Psychiatry PLLC a new, valid credit card which I will allow them to charge over the telephone. Even though Greater Heights Holistic Psychiatry PLLC is not processing the new card in person, I agree that the new card may be used with the same authorization as the original card I presented.

Signature

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Date

MEDICAL RECORDS RELEASE FORM

Patient's Name
DOB
Social security number

I authorize to release all my medical records from the below provided Date , including but not limited to, initial psychiatric evaluation, history and physical, progress notes ,procedure notes, medication history and lab reports

To Greater Heights Holistic Psychiatry from the following provider(s):

From Greater Heights Holistic Psychiatry to the following provider(s):

From Date
Provider's Name / Institution Name
Address
Phone Number
Fax Number

I understand that this form will be in effect for 1 year after termination of care from Greater Heights Holistic Psychiatry clinic. I understand that I can revoke this consent in writing at any time.

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MEDICAL AND PSYCHIATIC HISTORY

What are the problem(s) for which you are seeking help

1
2
3

Past Psychiatric History. Ever been diagnosed or treated with any mental health illness?

Previous psychiatrst Name

Any Psychiatric Hospitlization?

Current Therapist/Counselor

Past suicidal ideation/ attempt / plan

Medications for mental health reason

Medical and Surgical History:

Current Medications for Non-Psychiatric conditions:

Family Medical History ( if any)

Family Psychiatric History

Primary Care Physician with phone number

Are you planning to get pregnant in the near future?

Yes

No

Are you currently pregnant or do you think you might be pregnant?

Yes

No

What is your highest educational level or degree attained?

Do you have a history of being abused emotionally, sexually, physically or by neglect?

Yes

No

Legal History: Have you been arrested?

Yes

No

How many days a week do you get exercise?

Do you follow any particular diet ?

What kind of exercise do you do?

PHQ-9

Over the last 2 weeks, how often have you been bothered by any of the following problems? Please Select your answers.

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. *

Trouble concentrating on things, such as reading the newspaper or watching television. *

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. *

Poor appetite or overeating. *

Feeling bad about yourself – or that you are a failure or have let yourself or your family down.

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

Difficulty Level *

GAD 7

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling nervous, anxious, or on edge *

Worrying too much about different things. *

Trouble relaxing. *

Not being able to stop or control worrying. *

Being so restless that it’s hard to sit still. *

Becoming easily annoyed or irritable *

Feeling afraid as if something awful might happen *

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

Difficulty Level *