Child/Adolescent New Patient Form

Responsible Party (If other than the patient):

Parent/Legal Relationship to Child

What is your relationship to the child/patient?

Please select the option that best describes your relationship:

Scheduling Appointments

Please prepare to confirm your appointment with Visa or Mastercard; we will keep it on file. Self-pay patients need to make the full payment to confirm appointment.

Our practice will always accommodate your scheduled time, however, due to the complexity and
conditions of the patient ahead of you, there may be delays in which circumstances are
out of our hands. We appreciate your patience and cooperation during these times. Our staff will
do everything possible to provide the best treatment for you and your family needs. Please let us know your urgency upon arrival for your visit. We request that patients arrive 30 minutes prior to the
new patient visit and 15 minutes prior to the follow up visit. The appointment is final. Patient is responsible to keep the appointment to avoid no show fees ($380.00).

What to Bring:

• You MUST bring all your medication with the container with patient name and prescribing provider's information OR a list with this information.
• You MUST complete all forms on our website prior to the time of your appointment. Please sign the Release of Information so that we can obtain your previous medical records from your (Primary Care Doctor / Psychiatrist)

* Authorization for Care & Treatment, HIPAA Regulation & Consent, Payments Agreement, Patient Questionnaire, Release of Medical Records Form.

We must have your current and valid photo ID. If there is a child or adolescent, we will need the Child’s photo ID as well as the parent's. If you are adoptive parents, care providers, step-parents or custodial parents, we will need an adoption papers and official court orders with the authorization for the medication and treatment of the child.

For a new child or adolescent patient, we must have an initial visit with the parents only and then we will have an initial visit with the child or adolescent patient along with the parents.

For adult treatment of ADHD or ADD, the provider’s requires neuropsychological testing and urine drug screening before start of ANY stimulant medications.

***Please get neuropsychological testing ONLY done by a PHD level psychologist.***

Prior authorization of medication may take 7 days to get approval by the insurance company. Our office requires a follow up visit to receive prescription.

Office Policy

• If the patient misplaces (including lost or stolen) a controlled substance prescription within the time period before the next appointment, the prescribing physician will not write another prescription. It is the patient’s or guardian's sole responsibility to keep the prescription in a safe protected place.
• For the safety of our patients and staff, please do not bring any food or drink, any concealed weapons, or any sharp items. Any photography and/or video recording is prohibited.
• Any patient involved in litigation shall be responsible for all litigation-related fees and expenses arising between the parties. The patient agrees to indemnify and hold harmless Bay Hill Psychiatric Associates, its staff, Dr. Syeda Sultana, and all affiliated providers from any claims, costs, expenses, or liabilities arising from litigation, court-ordered subpoenas, or compliance with court orders.

We thank you for your patience and appointment request we will get back to as soon as possible to confirm you appointment.

Please type and print your name below as an acknowledgement of all the terms and condition regarding your appointment with our office:

AUTHORIZATION FOR CARE AND TREATMENT

1. I recognize that a condition exists requiring psychiatric/psychological care and do herby voluntarily consent to such care, medical care and treatment and diagnostic procedures by Bay Hill Psychiatric Associates, LLC (medical professional staffs, employees & agents) or as deemed necessary.

2. I hereby authorize the physician assigned, as provided by law, to furnish psychiatric/psychological care or therapy, including administration of psychiatric medication.

3. I am aware that the practice of medicine, including psychiatry and psychology, are not exact sciences, and I acknowledge that no guarantees have been made to me as to the result of diagnostic procedures, medical procedures, treatments, examinations or care undertaken.

4. The contents of this form have been fully explained to me and I have been given the opportunity to ask questions. Any questions which I have asked have been answered to my satisfaction. I certify that I understand the contents of this form and that all blanks have been crossed out or
filled in.

CONSENT FOR TELEMENTAL HEALTH SERVICES

1. Video conferencing technology is not the same as a direct patient/provider visit due to the fact that the psychiatrist and patient are not in the same room. Visual or auditory cues that are more apparent in-person may be missed in a video chat.

2. Confidentiality still applies for telemental health services, and nobody will record the session. However, you must make sure you are in a secure room where no one can hear your conversation and you can have minimal interruptions. Also, please use a secure internet connection rather than public/free Wi-Fi for your privacy.

3. As providers, we will also take every precaution to ensure technologically secure, HIPAA compliant, and environmentally private psychotherapy sessions. We cannot control freezing, crashing, or bad connections, but we will work with you every way we can to ensure the best possible interactions.

4. You will need access to a smartphone, webcam & audio enabled equipment, or a laptop for the telehealth appointment. Headphones or earbuds may improve sound quality and increase your privacy. Some clients may choose to sit in their car for the session for the utmost privacy.

5. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to tele mental health unless an exception to confidentiality applies (i.e. mandatory reporting of a child, elder, or vulnerable adult abuse; danger to self or others; mental/emotional health as an issue in a legal proceeding, physical health danger).

6. I understand that tele mental health is not a substitute for crisis/emergency services. For crisis/emergency services, please call the crisis hotline 800-273-8255. For a life-threatening emergency, dial 911, or go directly to your local hospital emergency room.

7. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that tele mental health services are not appropriate and a higher level of care is required. I understand that my tele mental health providers may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

8. I understand that a telehealth consultation has potential benefits including easier access to care, less potential exposure to COVID-19, and the convenience of meeting from a location in Florida of my choosing.

9. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. This will not jeopardize my access to future care, services, and benefits.

IN CASE OF TECHNOLOGY FAILURE: If service is disrupted due to a tech failure, please phone us at 407-903-9696. We may choose to reschedule if there are problems with connectivity.

STRUCTURE and COST OF THERAPY SESSIONS: Tele mental health sessions are the same fees as face to face sessions. Prior to any session, please verify insurance status and coverage. Please contact your insurance to verify coverage via tele mental health before engaging in it so that you are clear about what the cost will be to you. Payment is the responsibility of the patient or guardian regardless of insurance reimbursement and is due at the time of service.

RELEASE OF LIABILITY: I unconditionally release and discharge Syeda N. Sultana, M.D., Bay Hill Psychiatric Associates, LLC DBA Sakina Mind, providers, trainees, staffs, and employees, from any liability in connection with my participation in the remote consultations.

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me.

• That I fully understand its contents including the risks and benefits of the procedure(s).

• That I have had a direct conversation with the staff of the provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language which I understand.

HIPPA REGULATION AND CONSENT

Required by the Health Insurance Portability and Accountability Act --- 45 CFR Parts 160 and 164

Visit the link below to see HIPPA Regulations:

https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/administrative/combined/hipaa-simplification-201303.pdf

I hereby authorize Bay Hill Psychiatric Associates and its staff to leave messages containing the following information on my voicemail or answering machine:

1. Referral information
2. Prescription refill information
3. Test results
4. Appointment reminders

You may contact me regarding my treatment and care at the following numbers:

PAYMENT AGREEMENT

I clearly understand and agree that all services rendered to me personally and/or to a minor or other person under my guardianship are charged to my credit card directly to me and I am financially responsible for payment for the office visit (if not covered by insurance). There are no refunds or charge backs for services, missed appointments, and other charges.

I am responsible, as a self-pay patient, for an initial visit of $875.00 & follow up visits at $675.00 paid in advance at the time of appointments. Market place insured patients may have to pay self pay rate until we receive payment from insurance company. After reviewing the EOB, there will be refund will be provided to the Credit Card it was charged originally. If my insurance company refuses to confirm payment or my insurance expired at the time of my visit a self-pay visit rate will be charged to the credit card on file for the services.

I have read, understand and accept the payment instructions given to me at this time of my first visit.

THIS SIGNED FORM WILL SERVE AS MY SIGNATURE ON FILE, UNLESS OTHERWISE SPECIFIED. I GIVE PERMISSION TO DR. SYEDA N. SULTANA TO TREAT ME/MY CHILD AS HER PATIENT IN HER OFFICE/VIRTUALLY UNLESS OTHERWISE SPECIFIED IN WRITING.

CANCELLATION AND OTHER CHARGE POLICY

I understand that I will be charged for appointments not kept and which were not cancelled 48 hours in advance of the appointment time. Since insurance companies cannot be billed for this, I will pay for missed appointments, and I am personally responsible and authorizing no show fees to be charged to my card on file for such payment(s).

• $100.00 charge for new patient missed appointments. $380 for the self pay patient.
• $50.00 charge for follow-up missed appointments. $180 for the self pay patient.
• $40.00 charge for short term, long term, Medicare, Social Security, disability, any insurance company, CPA, court, attorney & FMLA documents.
• $40.00 charge (minimum) for any personal letters, medical record review/dispersement & any forms filled by the doctor.

I HEREBY AUTHORIZE SYEDA N. SULTANA, M.D. / BAY HILL PSYCHIATRIC ASSOCIATES, LLC TO RELEASE ALL INFORMATION NECESSARY TO SECURE PAYMENT AND ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND ACCEPTED THE FORGOING STATEMENTS.

Patient Questionnaire

Consent for Treatment and Limits of Liability

Benefits and Risks of Treatment

I understand that therapy may provide benefits such as reducing emotional distress, improving relationships, and addressing specific concerns. However, treatment outcomes cannot be guaranteed and may vary based on individual circumstances. I understand that discussing difficult experiences, thoughts, emotions, or aspects of my life may cause temporary emotional discomfort or distress.

Limits of Confidentiality

I understand that information discussed during treatment is confidential and will not be disclosed without my written authorization, except as permitted or required by law. Exceptions to confidentiality may include:

• Duty to Warn and Protect: If there is a serious threat of harm to myself or another person, the provider may be required to take appropriate protective measures, which may include notifying family members, law enforcement, or an intended victim, as permitted or required by law.

• Abuse or Neglect: Suspected or disclosed abuse or neglect of a child or vulnerable adult must be reported to the appropriate authorities as required by law.

• Prenatal Exposure: Information concerning prenatal exposure to certain controlled substances may be reportable as required by applicable law.

• Minors and Guardianship: Parents or legal guardians may have rights to access the records of non-emancipated minor clients, subject to applicable law.

• Insurance and Third-Party Payers: When treatment is billed to insurance or another third-party payer, information necessary for payment or coverage may be disclosed. This may include the diagnosis, services provided, dates of service, treatment plans, and other information permitted or required by law.

By signing below, I acknowledge that I have read and understand the potential benefits and risks of treatment and the limits of confidentiality described above.

Mood Disorder Questionnaire

Children's Depression Inventory (CDI)

Kids sometimes have different feelings and ideas.

This form lists the feelings and ideas in groups. From each group, PICK OUT THE SENTENCES THAT BEST DESCRIBE YOUR FEELINGS AND IDEAS IN THE PAST TWO WEEKS.

After you pick a sentence from the first group, go on to the next group.There is no right answer or wrong answer. Just pick the sentence that best describes the way you have been recently.

SNAP-IV Teacher and Parent Rating Scale

For each item, select the response that best describes this child.

RELEASE OF INFORMATION

Required by the Health Insurance Portability and Accountability Act --- 45 CFR Parts 160 and 164

I hereby Authorize:

Bay Hill Psychiatric Associates, LLC
Syeda N. Sultana, M.D.
Board Certified Adult & Child/Adolescent Psychiatrist
Tel: 407-903-9696
Fax: 407-903-9698
sakinamind.com

To:

The information requested or authorized for release or exchange pertains to:
a. Mental Health
b. Education
c. HIV/Transmitted disease
d. Drug or alcohol abuse

This authorization is valid for 90 days from the date below. I may cancel this authorization by signing, dating and writing “CANCEL” on this original form or by sending a written, signed and dated request to the doctor above indicating my desire to cancel. I understand that once my information has been released, the recipient might re-disclose it; my doctor has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my health evaluation and/or treatment.