CONTACT INFORMATION AND PERSONAL DATA

Today's Date *
Today's Date
Patient Name *
Patient Name
Patient Date of Birth *
Patient Date of Birth
Patient Address *
Patient Address
At what telephone number may we leave messages? *
At what telephone number may we leave messages?
Emergency Contact
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Is the patient solely responsible for paying the bill? *
If NO, then complete “Guarantor Information”
If the patient is less than 18 years old, or is an adult who has been adjudicated incompetent, please list the legal guardian(s).
If the patient is less than 18 years old, or is an adult who has been adjudicated incompetent, please list the legal guardian(s).
Guardian Phone
Guardian Phone
Are you currently taking medications for psychiatric, nervous or emotional problems? *
Have you previously taken medications for psychiatric, nervous or emotional problems in the? *
Have you been previously hospitalized for psychiatric reasons? *
Have you previously/currently seeing a therapist? *
Are you taking medications for medical purposes (not psychiatric medications)? *
Are there Family Members with a history of Psychiatric/Emotional difficulties? *
SOCIAL HISTORY
Are you currently a student? *
Are you working? *
Are you receiving disability? *
SUBSTANCE USE HISTORY
Do you drink alcohol? *
Have you previously experienced withdrawal symptoms related to using or stop using alcohol (e.g. the “shakes,” sweats, nausea, blackouts, seizures, etc.) *
Do you currently use any illicit drugs (including marijuana)? *
Have you previously used any illicit drugs? *
Have you previously been in a detox for drugs or alcohol? *
Have you previously participated in an alcohol or drug treatment program? *
Do you have any pending/current legal issues? *
For Child and Adolescent Patients
Birth and Developmental History
Did mother use drugs, prescribed meds, tobacco or alcohol during pregnancy? Yes No If yes, please describe use
Has social services (e.g. DFACS) been involved with you or your family?
Guarantor Information (complete only if the patient is NOT paying the bill)
Name of person responsible for bill
Name of person responsible for bill
Guarantor Address
Guarantor Address
Guarantor Phone
Guarantor Phone
Guarantor Employer Address
Guarantor Employer Address
The Guarantor will need to digitally sign Consent for Treatment and Office Policies.
RECORD RELEASE AUTHORIZATION
Date
Date
CONSENT FOR TREATMENT
I hereby agree to be treated by physicians and/or mental health professionals associated with Psychiatric Consultants of Atlanta, P.C. I agree that I am, or the Guarantor is, personally responsible for ensuring that all charges for services rendered are paid. I understand payment is due at the time of service and failure to pay my bill may result in termination of treatment. A late fee of 6% per annum may be assigned to any outstanding balance 30 days or more overdue. I authorize Psychiatric Consultants of Atlanta to provide information concerning my treatment to any physician or therapist who referred me to Psychiatric Consultants of Atlanta.
OFFICE POLICIES
1. Missed appointments will adversely affect treatment outcome. Patients (or Guarantor) will be charged $50 when a cancellation is not made within 24 hours of the scheduled appointment. “No shows” will be charged $50 for the missed appointment. If, for any reason, the doctor must cancel an appointment, the patient will be advised at the earliest possible time.
2. Full disclosure, at least to the extent possible, is essential to effective psychiatric treatment. Our doctors cannot adequately help you if they cannot become familiar with your medical and psychiatric history (including past/current psychotherapists and psychiatrists). Consent to review your medical and psychiatric history and to discuss your care with other clinicians is a condition of treatment.
3. Patients are under no obligation to continue services should they decide to terminate at any time. However, we strongly urge that the doctor be notified in person regarding this decision so that it can be discussed openly.
4. Psychiatric medications can be very effective and well tolerated if used properly. A few medications do have the potential to become habit-forming or abused. In order to minimize the likelihood of this happening, we require that you do not permit anyone else to prescribe you any of the medications that you receive from our doctors except in the case of an emergency. Treatment will need to be terminated if you cannot agree to this.
5. Your first appointment is an evaluation. Your doctor will let you know if they are in the position to offer services beyond this first session.
6. Any unpaid monies greater than 90 days past due may be turned over to a commercial collection agency. If this occurs, you will be responsible for all monies owed and total fees charged by the collection agency including cost of any legal fees.
Signature(s) below indicate understanding and agreement with all of the above policies