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New Patient Screening Form

Welcome

Below you will find our New Patient Screening Form.

This form will take approximately 15-20 minutes to complete.

Upon completing this questionnaire, our Billing Department will do a complimentary benefits verification to ensure that our clinic is able to accept your insurance. For those who are wishing to self pay/cash pay for our services, please indicate as such on this form. From there, our providers will review your completed Screening Form to determine if, based on their current caseloads, they are able to move forward with you as a patient.

Please do not hesitate to reach out with any questions that you have while filling out this form.

Thank you again for your interest in our clinic & we look forward to hearing from you!

New Patient Screening Form
(for adolescents)

Please complete the fields below for the person seeking services at our clinic:

Patient First Name

Patient Last Name

Patient Preferred Name

Patient Date of Birth

Patient Preferred Pronouns

Patient Gender

Guardian Full Name

Relationship to Patient

Guardian Phone Number

Street Address

Apt #

City, State, Zip

Guardian Email

How did you hear about us?

Who referred you to Collaborative Solutions in Psychiatry?

A little more about you...

I am interested in Psychiatric Management for my child / the patient (including medications and/or supplements.)

Yes

I am interested in Transcranial Magnetic Stimulation (TMS) Services for my child / the patient. (A non-medication treatment for severe depression and/or OCD. Approved by insurance for patients 18yo+)

Yes

I am interested in my child / the patient being evaluated and treated with possible medication for ADHD.

Yes

I am interested in IV-Ketamine for my child / the patient. (Off-label, medication infusions for treatment-resistant mood disorders. Private Pay ONLY-Not covered by insurance. *For patients 15yo+. EASTSIDE ONLY.*)

Yes

I am interested in Tension & Trauma Release Exercise (TRE™) Therapy for my child / the patient. (A non-medication treatment that may help with depression, anxiety, PTSD & chronic or acute stress.)

Yes

I would like in-person psychiatric appointments to take place at the:

Westside Location ONLY

Eastside Location ONLY

No preference / open to either location

In your own words, please explain your reason(s) for seeking services & any diagnoses you may be questioning for your child / the patient.

Please briefly describe your child’s / the patient’s current concerns. How old was your child / the patient when these concerns began?

Was the child's / patient's pregnancy & delivery full-term and without any complications? If not, please explain.

Primary Care Provider name & address:

Please note that while *not* having a PCP will not stop our initial intake process, in order to remain an active patient at Collaborative Solutions in Psychiatry, establishing with a PCP will be required. Required

I acknowledge and understand.

Child’s / Patient’s School, Address & Grade:

School Care Team:

Therapist’s name & address: (is applicable)

Collaborative Solutions in Psychiatry does NOT offer individual, couples, or group therapy / counseling services. Required

I acknowledge and understand.

Does your child / the patient have a current psychiatric prescriber? Required

Yes

If yes, who:

If yes, reason for leaving:

Please list any other medical diagnosis/conditions here:

Other: (such as Occupational Therapy, Speech Therapy, Birth-3 Provider, etc.)

If yes, please indicate number of attempts below:

Reason & details of hospitalization: (please include number of stays)

Details of commitment:

Has your child / the patient ever been aggressive towards:

Adults / Caretakers

Other children

Animals

Other

If selected any of the above, please explain.

If "yes", please summarize usage & what substances.

If "yes" selected for any of the above, please provide any details you are comfortable with sharing.

Does your child / the patient have/has had any serious medical illnesses? If so, please describe the illnesses & the treatment.

Please list any past or current psychological or psychiatric treatment your child / the patient has received.

Please list all currently prescribed psychiatric medications - including dosages and frequencies. (if none, indicate "none" below):

Please list who is currently prescribing the above medications; clinic location (if none, indicate "none" below):

Insurance Information

Primary Insurance Carrier

Member Number

Group Number

Subscriber Information (who holds this policy?)

First Name

Last Name

Patient relationship to subscriber

Subscriber DOB

Subscriber Phone Number

Front of Insurance Card

Upload File

Upload supported file (Max 15MB)

Back of Insurance Card

Upload File

Upload supported file (Max 15MB)

Please note, while these fields are not required, our billing department may not be able to verify benefits without a copy of your insurance card. A copy will need to be emailed to: moreinfo@csipmadison.com prior to establishing as a new patient at Collaborative Solutions in Psychiatry. Delays in uploading this information may cause delays in establishing care.

Secondary Insurance Carrier

Member Number

Group Number

Secondary Subscriber Information (who holds this policy?)

First Name

Last Name

Front of Insurance Card

Upload File

Upload supported file (Max 15MB)

Back of Insurance Card

Upload File

Upload supported file (Max 15MB)

Patient relationship to subscriber

Subscriber DOB

Subscriber Phone Number

Screening for TMS Services

If above you indicated interest in pursuing TMS services, please complete the additional screening questions below for us to see if TMS is right for you.

Are you 18 years old or older?

Yes

Have you been diagnosed with a seizure disorder?

Yes

Do you ave any metal or medical devices implanted in your head or chest?

Yes

Are you pursuing TMS for Severe Depression?

Yes

Have you received TMS before?

Yes

If "Yes" to having a seizure disorder provide details:

If "Yes" to having implanted metal or medical devices, provide details:

Are you pursuing TMS for OCD?

Yes

Have you taken medications for depression and / or OCD (include current and past)?

Yes, 4 or more different kinds.

Yes 2-3 different kinds.

Yes, only 1.

No, never.

I understand that the information provided above will be used in screening to determine my eligibility for services at Collaborative Solutions in Psychiatry. I acknowledge that they may not be able to take me on as a patient, and understand that completion of this form does not guarantee me becoming a patient.

I accept terms & conditions

After submitting this screening form, you will be directed to another link and asked to complete a short survey that captures a current status of your mental health symptoms.

By completing this survey,
Our review process will be expedited!

Still have questions?

Email our intake department today!

Mail

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New Patient Screening Form

Welcome

New Patient Screening Form (for adolescents)

A little more about you...

Insurance Information

Screening for TMS Services

Still have questions?

New Patient Screening Form
(for adolescents)