Adult Patient Intake Form

Please correct the errors described below.

MINI Patient Health Survey

Please list all other persons living in your household, as well as children not living in your home.

Add Additional Name

Please indicate past problems with "Past" and current problems with "Current"

Please indicate how the problems are affecting the following areas of you and your life

Add Additional Treatments

Add Additional Treatments

The undersigned patient or responsible party (parent, legal guardian or conservator) consents to, and

authorizes services, by Randall McIntyre These services may include psychotherapy, medication therapy, laboratory tests, diagnostic procedures and other appropriate alternative therapies.

The undersigned understands that he/she has the right to:

  1. Be informed of and participate in the selection of treatment modalities.
  2. Receive a copy of this consent.
  3. Withdraw this consent at any time.


If your answer to both questions above is "NO", please proceed to Section II without answering question 3 below.

3. Over the past two weeks, when you felt depressed or uninterested:


If your answer to this question is "NO", you have completed section II -please do not answer the questions below. Please proceed to Section Ill.

2. In the past 12 months:


If your answer to both questions above is "NO", please proceed to Section IV without answering any other questions below in Section Ill.

4.During the worst spell that you can remember:



This questionnaire should be used as a starting point. It is not a substitute for a full medical evaluation. Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your doctor.

Adult ADHD Self-Report Scale (ASRS-v 1.1) Symptom Checklist

Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your·healthcare professional to discuss during today's appointment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Office Policy

Fees and Payment (Revised Yearly)

Initial Evaluation (50 minutes)
Medication Check (25 minutes)
Psychotherapy (50 minutes)


Payment is due at each appointment. I do not currently accept insurance but am able to produce (paid) receipts which you submit to your insurance carrier for reimbursement. Late fees will accrue at a rate of $10 per month. Outside collections will be considered as a means of resolving all account balances with no payment activity after 90 days. It is the expectation we will complete all needed pre authorizations or paperwork together during office visits. If there is an urgent need for paperwork or pre-authorizations outside of an office visit with you, there will be fee of $50-$200 to be paid via electronic invoice prior to these commencement of services.

If a change to treatment is necessary, you will need to schedule an office visit by calling my office during normal business hours at (512) 687-3426. All questions ( e.g. medications) should be addressed during appointments so that I may have access to your patient file.

Cancellations and Missed Appointments

Please call to cancel or reschedule appointments at least two business days in advance. Appointments missed or cancelled less than 2 business day in advance will be billed at the full fee. PLEASE NOTE: Insurance Companies will NOT pay for missed visits.

Prescription Refills

All refills will be issued during your office visit. I do not, as a rule, phone or fax prescriptions. Please plan accordingly and call the office at (512) 687-3426 to come to an appointment before you run out of medication -generally the office will be able to schedule you within 3 to 4 days. Due to medical practice standards, if you are active patient, office visits will be required (at least) quarterly. Controlled substances (such as stimulants) require a paper prescription or electronic submission. Federal and state databases reporting controlled substance prescriptions are routinely monitored.


For established patients currently in treatment and needing to contact me urgently, you may reach me at the office (512) 687-3426 or by cell phone at 512-422-3565. Please note that I will not answer the phone when I am with a patient but will return your call as soon as possible. When leaving a message please include and repeat your full name and your phone number if you wish to be called back. Emergency calls are subject to emergency fees. In the event of a psychiatric or medical emergency, please call 911 or go to the nearest emergency department.

Contacting Me

As more individuals utilize electronic communication methods it is important to realize diagnosis or treatment via email or text is not appropriate. These methods of communication are not secure. If you have a simple question of a general nature, which does not include private information, you may use my email at rmcinty, Please do not text me. More complex questions can only be considered during appointments.

I have read and agree to the above office policies

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application and the undersigned is also financially responsible for fees.

HIPAA Privacy Policy

We are committed to respecting the privacy of our patients and maintaining the confidentiality of their protected health information. When you consent to treatment, you consent to the use of your information as outlined in our Notice of Privacy Practices. If we decide to change our Notice, such changes will be posted here on our web site. You may visit our web site and browse without giving us any personal information.

Notice of Privacy Practices (Effective January 30, 2012)


Our Pledge to You

Dr. McIntyre creates a detailed record of the care and services you receive at our office. By law, we must keep this record private. And we must give you this summary of our legal duties and privacy practices, and follow them. Our policies apply to all of the records of your care.

Who Will Follow These Privacy Practices

Dr. McIntyre provides health care in partnership with physicians, other health-care providers and agencies. These privacy practices will be followed by:

  • Any health care provider who treats you;
  • All employees and staff;
  • Any business associates that agrees to maintain your privacy.

Some Ways Your Medical Record May be Used or Shared

We may use or share medical information about you:

  • for treatment, such as a referral to a specialist or other health care agency;
  • for payment, such as your insurance company, Medicare or Medicaid;
  • for regulatory agencies such as during an audit or survey of our facilities;
  • with those whom you designate to be involved in your care;
  • in an emergency or disaster so that your family or friends can be told where you are and how you are;
  • when required for public health reports, abuse or neglect reports, funeral arrangements, and organ donation;
  • when required by law such as a request from law enforcement or a legal order;
  • when required by military authorities if you are a member of the military or a veteran;
  • for national security and intelligence activities, or for the protection of the President or others.

Other Ways That Information About You May be Used

Unless you tell us not to, we may use information that we have about you to:

  • Remind you of an appointment;
  • Recommend possible treatment options;
  • Tell you about health-related services;

Uses and Disclosures That Require Your Authorization

In any other situation not covered by this notice we will get your written authorization before using or sharing your health information, including release of psychotherapy records. You may revoke any authorization in writing.

Your Rights Regarding Medical Information About You

In most cases, you may review and obtain a copy of your medical record. There may be a fee for the cost to copy and mail it. Your request must specify how or where you wish to receive your medical record. We will honor all reasonable requests.

You may ask us to correct your record if you think that it is incorrect or that key information is missing. You must put your request in writing and state the reason for your request. We cannot revise your record if the information was not created by us; or is not part of the medical record we maintain; or is not part of the record that you can review or copy; or if we find out that the record is accurate.

You may get a list of when and to whom we gave your medical information. Such a list would not include the permitted disclosures outlined within this notice. Your written request for such a list must state a time period; requests will include a fee for our cost to produce the list. We will inform you of the cost before we process your request.

You may ask that we communicate medical information about you in a confidential way, such as sending mail to an address other than your home. We will honor all reasonable requests. Our waiting areas are shared with other patients. Please tell us if you object to this type of waiting or treatment areas. We will do our best to accommodate your request for privacy.

You may ask that we not use or disclose a certain part of your information as allowed by this notice unless you sign a consent to release the information. By law, we do not have to accept such a request, but we will seriously consider it and inform you of our decision. Your request must tell us what specific information you want to limit and to whom the limits apply.

Authorization to Release Protected Health Information

Changes to Privacy Notice

We may change our privacy policies at any time. Changes will apply to prior and new medical information. Before we make major changes in our policies, we will change our Notice of Privacy Practices and post the new notice in our office. You can get a copy of the current privacy notice at any time. The effective date is listed just below the title.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.