Diagnosis - Upstate Psychiatry – upstatepsychiatry.org



Return completed form via USPS, fax, or email included at the bottom of the pageCheck Requested Services____ TMS (Transmagnetic Stimulation) ***Please complete the TMS Intake Form on Website****____ Psychiatry (Medication Management) ____Therapy____ Christian Counseling____ Neuropsychological Testing____ Other: Specify__________________________Referral Source (if any): ________________________________________________________________Personal InformationName:________________________________________________ Date: ______________________ DOB: ______________________________ Age: _______ Parent/Legal Guardian (if under 18): ___________________________________________________ Address: _________________________________________________________________________ Cell Phone: __________________________ May we leave a confidential message? □ Yes □ No Home Phone: _________________________May we leave a confidential message? □ Yes □ No Email: ________________________________________ May we send a message? □ Yes □ No *Please note: Email correspondence is not considered to be a confidential form of communication. Marital Status: □ Never Married □ Domestic Partnership □ Married □ Separated □ Divorced □ Widowed □ Other ____________Gender Assignment at Birth: _______________ Gender Identity: ___________________________Preferred Pronouns: ________________________________________________________________Emergency Contact: _____________________________________________ Relationship to Patient: ___________________________________________ Cell/Home Phone: _______________________________________________ Employment Status (Select One) Full Time _____ Part Time _____ Homemaker _____ Retired _____ Disabled _____ Worker’s Comp ____Place of Employment (If applicable): ___________________________________________Do you currently have an on-going/pending Worker’s Compensation, Disability Case, or lawsuit related to the services you are seeking?Describe: ______________________________________________________________________________________Mental Health HistorySuicide AssessmentIn the past few weeks, have you felt that you would be better off if you were dead? □ Yes □ NoIn the past week, have you been having thoughts about killing yourself? □ Yes □ NoWhat would prevent you from killing yourself? _______________________________________Are you having thoughts of killing yourself right now? □ Yes □ NoIf yes, what plan do you have to kill yourself ___________________________________Have you ever tried to kill yourself? □ Yes □ No If yes, when ___________________________If yes, please describe: ______________________________________________________Do you have access to guns? If yes, explain _____________________________________________________________ Outpatient Psychiatric TreatmentName of ProviderReason for LeavingPsychiatrist/Psych NP □ Yes □ No □ N/ATherapist □ Yes □ No □ N/AOther (Describe)Inpatient Treatment Programs (Psychiatric, Substances, Eating Disorder, etc.)Name of FacilityDescribe (Dates, Reason, etc.)Psychiatric Eating DisorderSubstance Abuse Rehabilitation/TreatmentFamily HistoryDiagnosisFamily MemberTreatment/Medication (if known) Current Symptoms: Check all that apply__ Depressed mood __ Racing thoughts__ Trauma history( ) Excessive worry__ Too much, too little sleep__ Unable to enjoy activities__ Impulsivity__ Avoidant behavior( ) Anxiety attacks__ Too much, too little sleep__ Sleep pattern disturbance__ Decreased need for sleep__ Hallucinations( ) Avoidance__ Too much, too little sleep__ Poor concentration/forgetfulness__ Excessive energy__ Paranoia( ) Hallucinations__ Too much, too little sleep__ Significant change in appetite__ Irritability__ Feeling suicidal( ) Suspiciousness__ Too much, too little sleep__ Excessive guilt__ Crying spells__ Recent suicide plan/attempt( ) __ Too much, too little sleep__ Fatigue__ Excessive worry( ) __ Too much, too little sleep__ Change in libidoAdditional Comments/Information:__ Anxiety Attacks__ Too much, too little sleepPast Psychiatric Medications (Circle all that apply)Prozac (fluoxetine)Zoloft (sertraline)Luvox (fluvoxamine)Paxil (paroxetine)Celexa (citalopram) Lexapro (escitalopramEffexor (venlafaxine)Cymbalta (duloxetine)TrintellixFetzimaViibrydWellbutrin (bupropion)Remeron (mirtazapine) Serzone (nefazodone)Anafranil (clomipramine)Pamelor (nortriptyline)Tofranil (imipramine)Elavil (amitriptyline)Tegretol (carbamazepine)LithiumDepakote (valproate)Lamictal (lamotrigine)Topamax (topiramate)Seroquel (quetiapine)Zyprexa (olanzapine)Geodon (ziprasidone)Abilify (aripiprazole)Clozaril (clozapine)Haldol (haloperidol)Risperdal (risperidone) Ambien (zolpidem)Sonata (zaleplon),Rozerem (ramelteon)Restoril (temazepam)Desyrel (trazodone) Adderall (amphetamine-dextroamphetamine)Ritalin/Concerta (methylphenidateStrattera (atomoxetine)Xanax (alprazolam)Ativan (lorazepam)Klonopin (clonazepam)Valium (diazepam)Suboxone (buprenorphine)Other ____________________________________Substance AbuseHave you ever felt you should cut down on your drinking or drug use? □ Yes □ NoHave people annoyed you by criticizing your drinking or drug use? □ Yes □ NoHave you ever felt bad or guilty about your drinking or drug use? □ Yes □ NoDo you drink/use drugs first thing in the morning to steady your nerves or get rid of a hangover? __□ Yes □ NoDrug NameHow LongLast UseCommentsAlcoholMethamphetamineCocaineStimulantHeroinLSD/HallucinogensMarijuanaPain KillersMethadoneTranquilizers/sleeping pillsEcstasyOther Legal HistoryHave you ever been arrested? Describe any pending legal issues: ___________________________Personal Health HistoryPrimary Care Provider ____________________________Contact Information __________________Current Height/Weight _________________ Allergies ____________________________Date and place of last physical exam _________________________________________Date of last lab testing (if applicable) ________________________________________Date of last EKG (if applicable) _______ Results of EKG (circle one) normal abnormal unknownRelevant Medical IssuesMedical DiagnosisYesNoDescribeMedication (name, dose)Thyroid DiseaseHeart DiseaseLiver DiseaseDiabetesRespiratory DiseaseChronic PainEpilepsy/SeizureHead Trauma/ConcussionGastrointestinalMetal ImplantsSurgical HistorySurgeryDateProcedureComplicationsPrescription, Non-Prescription, and Over-the-Counter Medication UseMedication NameDose/How OftenPrescriber (if applicable)Reason for Medication UseFemales OnlyLast Menstrual Period Date _________________________________________________ Are you now, or do you plan on becoming pregnant in the near future □ Yes □ No Post-Menopausal □ Yes □ No Consent for TreatmentThe following information is to be completed by the patient or the patient’s legally authorized representative/parent:I consent to medical treatments for myself or for the patient for whom I am the parent or legally authorized representative. I understand that Upstate Psychiatry will share patient health information according to state and federal law for treatment, payment, and operations. I understand that I am responsible for all charges incurred, regardless of the patient’s insurance status. I agree to pay for services as the patient incurs the charges. I authorize the insurance provider to pay Upstate Psychiatry for services rendered. Completion of this form does not guarantee services. We encourage you to continue to explore mental health options within the community while awaiting response from Upstate Psychiatry. This clinic is not a comprehensive/specialty clinic and complex patients will be referred to appropriate resources.Signature of Patient: ___________________________________ Date: ______________________Signature of Legally Authorized Representative: _______________________ Date: ______________ Relationship of Legally Authorized Representative to Patient: ________________________________ Insurance InformationPlease Refer to for Accepted Insurance PlansPrimary Insurance InformationPrimary Insurance __________________________________________________Primary Subscriber Name ____________________________________________Primary Subscriber Date of Birth _______________________________________Subscriber ID Number ________________________________________________Group Number (if applicable) ___________________________________________Secondary Insurance Information (if applicable)Secondary Insurance __________________________________________________Subscriber Name ____________________________________Secondary Subscriber Date of Birth _______________________________________Subscriber ID Number ________________________________________________Group Number (if applicable) __________________________________________ ................
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