Insights Psychiatric

Thank you for choosing Insights Psychiatric and we look forward to meeting you soon. Please let us know if you need any assistance filling this out, we are happy to help!

First Name

Last Name

Address

City

Zip code

Phone number

Email address

To onboard, we text your phone and send an email link. Is that ok with you? Your contact information will be used solely for the purpose of contacting you to provide the services you are requesting, and will not be shared outside of our HIPAA compliant software.

Yes No

Where did you hear about us?

My Doctor My insurance provider Headway Insights Psychiatric website Google search Other

Name of your doctor

Where did you hear about us?

Do you have preferences for your visit? Please let us know below.

Location (Telehealth or In-Person)

Day of the Week

Time of Day

First available

No preference

Would you like to be seen in person or on telehealth?

Telehealth (zoom) In-Person

Please pick the days that work best.

Monday

Tuesday

Wednesday

Thursday

Friday

Any day

Please pick the times that generally work best for you.

Morning

Lunchtime

Afternoon

Late in the day

My schedule varies

Do you have insurance?

Yes No

Are you planning to pay cash?

Yes No

The cash pay price is $500 for an intake visit. I am ok with this charge.

Yes No

What is your date of birth?

First name of Policy Holder

Last name of Policy Holder

Birth Date of Policy Holder

What is the name of your insurance company?

What is your member ID?

What is your group number?

What would you like to be seen for at Insights Psychiatric?

Are you requesting to be seen for a psychiatric disorder, substance use disorder or have you recently been admitted to an inpatient unit?

Yes No

If yes, please explain here.

Are you currently on or recently been taking psychiatric medications?

Yes No

Please list any psychiatric medications are you taking here.

At Insights Psychiatric we do not fill out paperwork for Social Security, long-term disability, workman’s comp, or any court related/ ordered paperwork. Established clients (defined as 4 or more visits) may request FMLA, short term disability, or time off work paperwork, but this is not a guarantee we will complete this paperwork. Filling out any paperwork is based on judgement and at the discretion of the provider. Do you understand and accept this policy?

Yes No

Are you requesting this appointment for ADHD medications or testing?

Yes No

It is the policy of Insights Psychiatric that all clients requesting ADHD diagnosis and medications be tested using a 3rd party computerized program. Unfortunately, most commercial insurances will not reimburse for this cost. When insurance does not cover the cost the client will be responsible for the testing fee (but we will always let you know ahead of time). Do you understand and accept this policy?

Yes No

Based on the personal medical history, diagnosis, treatment plan and the risks/benefits involved, it is ultimately the provider’s discretion whether or not to continue current medications. Medications you are currently taking may or may not be filled based on the provider’s professional judgement.

I understand medications requested may not be filled if the provider deems them not appropriate. I do not agree to allow the provider to change my medications.

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