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New Patient Screening Form

Welcome

Below you will find our New Patient Screening Form.

Upon completing this questionnaire, our Billing Department will do a complimentary benefits verification to ensure that our clinic is able to accept your insurance. We are not able to accept self-pay at this time. 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

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

Preferred Name

Full Legal Name (as it appears on the insurance card.)

Date of Birth

Preferred Pronouns

Gender Identity

Sex (assigned at birth.)

Phone Number

Street Address

Apt #

City, State, Zip

If someone else other than the patient, who & why?

Who referred you to CSIP? How did you hear about us?

How do you prefer to be contacted? (check all that apply. *please note: CSIP will give you a phone call after not hearing from you for some time.) Required

Phone

Text

A little more about you...

I am seeking evaluation by a psychiatric provider and treatment with prescribed medications or supplements for my current or possible diagnosis.

Yes

I am seeking evaluation for and treatment with prescription medication for ADHD.

Yes

I am seeking Transcranial Magnetic Stimulation (TMS) Services (A non-medication treatment for severe depression and/or OCD. Approved by insurance for patients 15yo+). Click info button to learn more.

Yes

Info

I am seeking IV-Ketamine (Off-label, medication infusions for treatment-resistant mood disorders. Private Pay ONLY- EAST SIDE ONLY.) Click info button to learn more.

Yes

Info

I am seeking Tension & Trauma Release Exercise (TRE™) Therapy. (A non-medication treatment that may help with depression, anxiety, PTSD & chronic or acute stress.) Click info button to learn more.

Yes

Info

I would like my 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.

Please list any other medical diagnosis/conditions here:

CSIP does NOT offer individual, couples, or group therapy / counseling services. Required

I understand and acknowledge that I am NOT seeking therapy services.

Please note you must establish care with a PCP in order to continue receiving care from CSIP. Required

I acknowledge and understand.

Are you seeking to transfer your psychiatric care from someone else to CSIP? Required

Yes

If yes, who & why? What can we offer that will best meet your needs?

If not, please provide the name & contact of the decision maker.

Do you have a family member, significant other or friend who is seen at CSIP? If so, who is the patient? (Please note: CSIP prefers that you see a provider who is not seeing someone you know.)

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):

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

Insurance Information

Primary Insurance Carrier

Member Number

Group Number

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)

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.

Patient relationship to subscriber

Subscriber DOB

Subscriber Phone Number

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 15 years old or older?

Yes

Have you been diagnosed with a seizure disorder?

Yes

Do you have 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.

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.

Still have questions?

Email our intake department today!

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