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New Patient Screening Form

Welcome

Below you will find our New Patient Screening Form. 

This form will take approximately 5-10 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

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

A little more about you...

I am interested in psychiatric medications and/or supplements
I am interested in Transcranial Magnetic Stimulation (TMS) Services (Non-medication treatment for severe depression and/or OCD. Approved by insurance for 18+)
I am interested in being evaluated and treated with possible medication for ADHD.
I am interested in IV-Ketamine (Off-label, medication infusions for treatment-resistant mood disorders. Private Pay only-Not covered by insurance at this time.)
Please select any current diagnosis:
Do you have a Primary Care Physician
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.
Do you have a current therapist
Collaborative Solutions in Psychiatry does not offer individual, couple, or group counseling services.
Do you have a current psychiatric prescriber

Insurance Information

Subscriber Information (who holds this policy?)

Upload File
Upload File

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 Subscriber Information (who holds this policy?)

Upload File
Upload File

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.

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?
Have you been diagnosed with a seizure disorder?
Do you ave any metal or medical devices implanted in your head or chest?
Are you pursuing TMS for Severe Depression?
Have you received TMS before?
Are you pursuing TMS for OCD?
Have you taken medications for depression and / or OCD (include current and past)?
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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!

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