Stonehaven Psych Care: Prospective Patient Pre-screening Form

Clinical Consultation Request

Please complete this form and a member of our staff will reach out to you regarding your inquiry for an appointment. This pre-screening form aids prospective and potential patients and providers to determine if the the psychiatric needs and services of the patient can be met. Since provider clinical skills, schedules, and insurance coverage vary, this form assists in the process to determine whether a provider is a good fit for the needs of each unique patient. If you are currently experiencing a medical or psychiatric emergency (for example: suicidal or homicidal ideation, medication adverse effects) please seek immediate medical attention by calling 911 or going to your nearest emergency room.

This inquiry is NOT for an urgent nor emergency appointment and I wish to proceed.

Patient First Name

Patient Last Name

Preferred Pronouns

Gender

Date of Birth

Phone Number

Email Address

Do you allow Stonehaven Psych Care PLLC to leave a voicemail or email message to the provided contact information above? Please specify.

Residential Address

How did you hear about us?

Please provide any information regarding the patient inquiring about treatment.

What type of psychiatric care is being considered? (Select all that apply)

Medication Management

Psychotherapy

Unsure

Are you currently prescribed any psychiatric medications? If yes, please specify the name, doses, frequency below:

Have you taken psychiatric medications in the past? If so, please specify name of medication(s).

If you have been psychiatrically hospitalized, please specify the hospital name and date(s).

If you have not been psychiatrically hospitalized, please write "No- not applicable."

Have you ever experienced thoughts of suicide?

Are you CURRENTLY experiencing suicidal thoughts? If yes - PLEASE CALL 911 or 988

If using insurance plan mentioned above, please specify the policy ID number:

For Out-of-Pocket/Self-Pay, enter "N/A"

Please specify the name of your health insurance plan:

If your insurance is your primary form of payment and you have not met your Health insurance deductible, you will be responsible for the full amount of payment for your appointment session. All payments are due at the time of the appointment. Do you understand and agree to these terms?

I agree I do not agree

Do you have Medicaid?

Yes No

Do you have Medicare?

Yes No

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