Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 11**Disclaimer – Referral required Fax to 850-433-1996** Patient InformationLocation *— Select Choice —FloridaAlabamaDate *Patient Name *FirstLastDate of Birth *Sex *MaleFemaleTransgender MaleTransgender FemaleUnspecifiedEmail *Phone *Mailing Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryCurrent or Previous Occupation *Marital Status *SingleMarriedDivorcedWidowedReason for appointment *— Select Choice —Medication ManagementTMSNeuro/PsychEMERGENCY CONTACT INFORMATIONEmergency Contact's Name *FirstLastContact Number *Relation to Client *INSURANCE PROVIDERInsurance Provider *Group NumberID NumberRelationship to Policy Holder Date of Birth *#SS *NextCurrent Medications *Include name, strength and times per day taken *Previous Psychiatric Medications *Include name, strength, times per day taken and reason for stoppingAllergies – Please list any medication allergies below or NONE along with reaction to eachNextMedical History – Please indicate any condition below that applies to your personal medical historyDiabetesMigrainesFibromyalgiaHeart DiseaseSeizuresAnxietyAlzheimer’sHypertensionChronic PainIBSHead InjurySleep ApneaDepressionParkinson’sHigh CholesterolGERDThyroid Disease (Hyper/Hypo)CancerStrokeADHDAlcoholism/Drug AbuseOtherHave there been any changes to the followingWeightEnergy LevelAbility to Sleep* Please add additional details for any changes to the aboveCurrent Prescribing PhysicianFirstLastPlease list your most recent blood work tests and resultsPlease list the date of any Psychiatric Hospitalizations, location, and reason for admissionPlease list the problems or concerns you would like to discuss belowNextSocial HistoryCurrent EmploymentHighest Level of EducationExercise HabitsCaffeine IntakeCoffeeTeaSodaEnergy DrinkOtherHow often do you consume the above?Please list how much and how often you drink or consume each. Example: 2 cups a day during the weekLiving SituationWith Spouse/PartnerWith ParentsWith ChildrenOtherAre you sexually active? ( If yes, are you trying for pregnancy?) and/or Informed yourself Do you use any of the followingAlcoholTobaccoLegal/Illegal DrugsPlease describe the use of the above Please list how much and how often you use each of the above. Example: 1 pack a day smoker for last 5 yearsPlease provide addtional information about any medical history or concerns you would like to discuss belowNextPatient Health Questionnaire – 9 (PHQ – 9)Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Little interest or pleasure in doing things Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Feeling down, depressed or hopeless Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Trouble falling or staying asleep, or sleeping too much Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Feeling tired or having little energy Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Poor appetite or overeating Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Feeling bad about yourself – or that you are a failure or have let yourself or family down Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Trouble concentrating on things, such as reading the newspaper or watching television Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day 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 Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Thoughts that you would be better off dead or of hurting yourself in some way Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day If you checked off any problems above, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?Not difficult at allSomewhat difficultVery DifficultExtremely DifficultNextNotice of Privacy Practices/HIPAABelow are links to each form required for new patient evaluation and treatment. Please sign/acknowledge where indicated. NOTICE TO PATIENTS REGARDING PRIVACY OF HEALTH INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISLOSED AND HOW YOU CAN GET ACCESS TO THlS INFORMATION. PLEASE REVIEW IT CAREFULLY. UNDERSTANDING YOUR HEALTH RECORD /INFORMATION Federal regulations developed under the Health Insurance Portability and Accountability Act (HIPAA) require that this Practice provide youwith this notice regarding Personal Health Information (PHI). Each time you visit a healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This information often referred to as your health or medical record serves as a: basis for planning your care and treatment means of communications among other health professionals who contribute to your care legal document describing the care you received means by which you or a third party payer can verify that services billed were actually provided a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve Understanding what is in your record and how your health information is used helps you to ensure its accuracy better understand who, what, when, where, and why others may access your health information make more informed decisions when authorizing disclosure to others Protected Health Information (PHI) is any health information created or received by your health care provider that contains foformation that may be used to identify you, such as name, address, tdephone numbers, and account numbers, or your condition. It includes written or oral health information that relates to your past, present, or future mental health; the provision of health care to you; your past, present, or future payment for health care YOUR HEALTH INFORMATION RIGHTS Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to: request a restriction on certain uses and disclosures of your information as provided by 45 CFR 522 obtain a paper copy of the notice of information practice upon request inspect and copy your health record as provided for in 45 CFR 524 amend your health record as provided in 45 CFR 528 obtain an accounting of disclosures of your health information as provided in 45 CFR 528 request communications of your health information by alternative means or at alternative locations OUR RESPONSIBILITIES The Practice is required to: maintain the privacy of your health information provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you abide by the terms of this notice notify you if we arc unable to agree to a requested restriction accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations We reserve the right to change our practice and to make the new provisions effective for all protected health information we maintain. Should our information practice change, we will mail a revised notice to the address you’ve supplied us. We will not use or disclose your health information without your authorization, except as described in this notice. USE AND DISCLOSURE OF PHI IN TREATMENT, PAYMENT AND HEALTH CARE OPTIONS Your Protected Health Information (PHI) may be used and disclosed by this Practice in the course of providing treatment, obtaining payment for treatment, and conducting health care operations. Any disclosures may be in writing, electronically, by facsimile, or orally. Additionally, this Practice may also use your PHI to remind you of an appointment, inform you of potential treatment alternatives and inform you of health-related benefits or services that may be of interest to you. OTHER USES OR DISCLOSURES PERMITTED WITHOUT AUTHORIZATION In addition to treatment, payment, and health care operations, our Practice may use or disclose your PHI without your permission or authorization in certain circumstances including.: when legally required to comply with any federal, state or local laws that involve disclosure of your PHI when there are risks to public health as permitted or required by law to report abuse, neglect, or domestic violence if it is believed that the patient is a victim to conduct health oversight activities such as audits or civil administrative, or criminal investigations, proceedings, or actions for judicial and administrative proceedings authorized by an order of a court or administrative tribunal for law enforcement purposes to coroners, funeral directors, and for organ donation in such cases as identification, dctcr:mination of cause of death, and/or performance in the medical examiners duties authorized by law for research purposes if such use has been approved by a review board or privacy board for specified government functions as authorized by HIPAA privacy regulations in correctional institution situations when information is necessary for your health, and the health and safety of other individuals *If you believe your privacy rights have been violated you can file a complaint with the Director of Health Information Management or with the Secretary of Health Services. There will be no retaliation for filing. Please ackowledge you have been provided a copy of your privacy information * Clear Signature SignatureNextCONTROLLED SUBSTANCE AGREEMENT The purpose of this Agreement is to prevent any misunderstandings about certain medicines you may be prescribed by the physicians or nurse practitioners at this clinic. This is to help both you and your provider to comply with the law regarding controlled pharmaceuticals. I understand that this Agreement is essential to the trust and confidence necessary in a doctor patient relationship and that my provider undertakes to treat me based on th.is.Agreement. I understand that if I break this Agreement, my provider may stop prescribing me certain medications and/or release me from the practice. In this case, my doctor will taper me off the medicine over a period of several days, as necessary, to avoid withdrawal symptoms. Also, a drug-dependence treatment program may be recommended I will communicate fully with my provider about the character and intensity of my symptoms, the effect of the symptoms on my daily life, and how well the medicine is helping to relieve my symptoms. I ·will not use any illegal controlled substances, including marijuana, cocaine, etc. I will not share, sell, or trade my medication with anyone. I will not attempt to obtain any controlled medicines, including benzodiazepines, controlled stimulants, or anti-anxiety medicines to treat the same symptoms from any other doctor. I will safeguard my medication from loss or theft. I understand that lost or stolen medicines will not be replaced. I agree that refills of my prescriptions for controlled medication will be made only at the time of an office visit or during regular office hours. No refills will be available during evenings or on weekends. I agree to notify my doctor and/or his staff if I change my pharmacy and I agree to use the same pharmacy for fulfilling all of myprescriptions. I authorize the doctor and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state’s Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my medication. I authorize my doctor to provide a copy of this agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. I agree that I will submit to a blood or urine test if requested by my doctor to determine my compliance with prescribed treatment I agree that I will use my medicine at a rate no greater than the prescribed rate and that the use of my medicine at a greater rate will result in my being without medication for a period of time. Name Of Pharmacy *Pharmacy Location *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePatient Name *FirstLastDate of Birth *Patient Signature * Clear Signature NextFinancial Policy Thank you for choosing The Anchor Clinic. We are committed to your successful treatment. The following is our financial policy which we request that you read, understand, and sign prior to treatment. Payments All payments (i.e., co-pays, co-insurance, deductibles) are due at the time of service. Payments are accepted in the form of cash, check, money order, and credit card (Visa, Mastercard, Discover, Amex). Appointment Cancellation Policy If you are unable to make your scheduled appointment, we must be notified at least 24 hours in advance. If our staff does not receive proper notification, the time scheduled with your clinician becomes am issed opportunity and delay for another client to be seen. Therefore, if an appointment is missed or not cancelled with proper notification, a fee will be applied to your account and with your permission, your credit card will be charged. A fee of$ 180.00 is applied for any new patient or testing appointments. The fee for missing follow-up appointments is $110.00. This fee is not billed to insurance, it is the patient’s responsibility and must be paid prior to rescheduling any future appointments. If more than two sessions are missed without proper notification, continued services can be discontinued. **Please note: Appointment confirmations are a courtesy ONLY. You are responsible for keeping track of your appointment date and time. Forms completed by our providers Health insurance does not cover form fees (e.g., ESA, FMLA, accommodation letters). An $80/$160 form fee must be paid prior to completion of forms. Billing Balances are due upon receipt of account statements. ln most cases, management can set up a payment arrangement with clients having trouble paying their balances in full to avoid it being turned over to a collection agency. Accounts must remain in good standing to continue receiving treatment at The Anchor Clinic. Returned Checks A $30.00 service fee will be added to your account for each returned check from your bank. Only cash payments will be accepted if two NSF checks are received. My signature below ackowledges I have read, fully understand and agree to the financial policy above. * Clear Signature My signature above acknowledges that I have read, fully understand, and agree to all parts of this financial policy. I also understand that my account may be turned over to a collection agency if it becomes delinquent.NextAUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION This form will allow the Anchor Clinic to correspond with others about your care. Please complete for any person or healthcare provider with whom we may discuss your care. A separate form is required for each party. Section A: (Must be completed for all authorizations) I hereby authorize the use or disclosure of my individual identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or a health care provider, the released information may no longer be protected by the federal privacy regulations. I give my permission to release confidential/sensitive mental health treatment records including HIV test results, alcohol and drug therapy, and lab reports. Patient Name *FirstLastSSN# *Date of Birth *Person and/or Organization providing the information *Authorization ForAllow two-way communicationInclude All RecordsInclude Only Specific RecordsIf you chose specific records, please describe belowThe patient or the patient's representative must read and check each of the follwing statementsI understand that my healthcare and the payment of the healthcare will not be affected if I do not sign this form.I understand that I may see a copy of the information described on this form if I ask for it and I may receive a copy of this form after I sign it.Signature of patient or representative * Clear Signature (Form must be completed with signature) I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do it will not have any affect on my actions they took before they received the revocation. *You may refuse to sign this authorization.Relationship to PatientNextAuthorization For Release of Information to Another Person – Patient Name and DOBNOTICE: This authorization is for full disclosure of pertinent mental health treatment records, including HIV test results, alcohol and drug therapy, and lab reports. If there is any information that you do not want disclosed to the named party, please indicate below what portions of the record you would like excluded. Please list the family members, spouse, or other person(s), if any, to whom we may release your personal medical information. If authorized, Anchor Clinic may release your information to any authorized person(s) in person or via telephone regarding your general medical condition and/or your diagnosis (including treatment, payment, and health care operations). These records are confidential and not for re-release by any facility other than Anchor Clinic. Name *FirstLastName *FirstLastName *FirstLastSignature of Patient or Legal Guardian * Clear Signature I hereby grant Anchor Clinic the approval to discuss my medical history as outlined above. Any exclusions have been noted. I understand that this authorization is voluntary and will remain in effect until rescinded by myself in writing. Patient or Representative Signature Clear Signature NextInformed Consent for Mental Health Evaluation/TreatmentBy checking the boxes below you agree to each statement listed. Please check all that you consent to I hereby voluntarily consent to a mental health evaluation including psychological testing. I understand that these are primarliy non-invasive, pencil and paper tests given for my benefit to better understand my health care condition. I know the results and issues discussedare private and cannot be communicated to anyone without my consent.I hereby voluntarily consent to mental health treatment. I understand that this includes psychotherapy (talk therapy), either individually or with my family as well as medication management. I know that issues I discuss are private and cannot be communicated to anyone else without my consent.I have been requested to participate in a court-ordered psychological evaluation/treatment program. The results of the evaluation or treatment progress will be reported to the agency below.Is the patient required by a court ordered mandate for treatment or evaluation?YesNoCourt AgencyIf yes to the above please provide which agency Is the patient part of a workers compensation claim?YesNoContinuedI voluntarily consent to treatment for myself or child.I voluntarily consent for my records (or my child’s) to be reviewed by the clinic regarding potential eligibility for participation in clinic research trials. I also give consent to be conatacted regarding optional participation in clinical research trials.Patient or Legal Guardian Signature * Clear Signature Patient Name *FirstLastIs this patient under the age of 18 or unable to consent on their own behalfYesNoCustom Captcha *What is 7+4? Submit
