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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:

First Name

Last Name

Preferred Name

Preferred Pronouns

Date of Birth

Gender

Phone Number

Preferred Language Spoken

Who is completing this form?

Street Address

City/State/Zip

How did you hear about us?

Who referred you to Collaborative Solutions in Psychiatry?

A little more about you...

I am interested in psychiatric medications and/or supplements

Yes

I am interested in Transcranial Magnetic Stimulation (TMS) Services (Non-medication treatment for severe depression and/or OCD. Approved by insurance for 18+)

Yes

I am interested in being evaluated and treated with possible medication for ADHD.

Yes

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.)

Yes

In your own words, please explain your reason(s) for seeking services

Please list any other medical diagnosis/conditions here:

Do you have a Primary Care Physician

Yes

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.

I acknowledge and understand.

Do you have a current therapist

Yes

Collaborative Solutions in Psychiatry does not offer individual, couple, or group counseling services.

I acknowledge and understand.

Do you have a current psychiatric prescriber

Yes

If yes, who:

If yes, reason for leaving:

If yes, please indicate number of attempts below

If "yes" selected for any of the above, please share as you are comfortable below (please indicate number of hospital stays):

If "yes" please summarize current use (including what substance(s)) below:

Please list all currently prescribed psychiatric medications and dosages (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 and dosages (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

Front of Insurance Card

Upload File

Back of Insurance Card

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.

Are you seeking private/cash pay options?

Subscriber Date of Birth

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

Back of Insurance Card

Upload File

Patient relationship to subscriber

Subscriber Date of Birth

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.

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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