Psychiatric Evaluations and Medication
Management Telehealth Services
Client Intake Form
Welcome! Thank you for choosing our telehealth services. This form will help us gather important information to determine your suitability for virtual psychiatric evaluations and medication management. Please answer all questions to the best of your ability. All information provided is confidential and will be used solely for the purpose of your care.
I. Personal Information
First Name
Last Name
Date of Birth
Gender Identity
Preferred Pronouns
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Phone Number
Email Address
Emergency Contact Name
Emergency Contact Phone Number
Relationship to Emergency Contact
II. Insurance Information
Insurance Provider
Member ID
Group Number
Policy Holder Name
Policy Holder Date of Birth
III. Reason for Seeking Services
What are your primary concerns or symptoms? (Please describe in detail)
How long have you been experiencing these concerns?
Have you received mental health services in the past?
If yes, please provide details: (Provider, Dates, Diagnosis, Treatment)
Are you currently receiving mental health services from another provider?
If yes, please provide details: (Provider, Specialty, Contact Information)
Have you ever been hospitalized for psychiatric reasons?
If yes, please provide details: (Dates, Reason, Hospital)
Have you ever attempted suicide or had thoughts of harming yourself or others?
If yes, please provide details:
IV. Medical History
Primary Care Physician (PCP) Name
PCP Phone Number
List any current medical conditions:
List any current medications (including over-the-counter and supplements):
List any allergies (medications, food, environmental):
Have you ever experienced seizures, head injuries, or neurological problems?
If yes, please provide details:
Do you have a history of substance use (alcohol, drugs)?
If yes, please provide details: (Type, Frequency, Duration)
V. Psychiatric Evaluations (Select all that apply)
General Psychiatric Evaluation: (Comprehensive assessment of mental health symptoms)
Mood Disorder Evaluation: (Depression, Bipolar Disorder, etc.)
Anxiety Disorder Evaluation: (Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, etc.)
Attention-Deficit/Hyperactivity Disorder (ADHD) Evaluation
Trauma/PTSD Evaluation
Obsessive-Compulsive Disorder (OCD) Evaluation
Personality Disorder Evaluation
Other (Please specify):
VI. Medication Management
Have you taken psychiatric medications in the past?
If yes, please list medications and their effectiveness:
Are you currently taking any psychiatric medications?
If yes, please list medications, dosages, and frequency:
Potential Medications (Common Examples - Subject to Provider Assessment):
Antidepressants: (SSRIs, SNRIs, TCAs, MAOIs, etc.)
Anti-anxiety Medications: (Benzodiazepines, Buspirone, etc.)
Mood Stabilizers: (Lithium, Valproate, Lamotrigine, etc.)
Antipsychotics: (Atypical, Typical)
ADHD Medications: (Stimulants, Non-stimulants)
Sleep Aids
Other (Please specify):
VII. Telehealth Suitability
Do you have access to a reliable internet connection?
Do you have a device with a camera and microphone (smartphone, tablet, computer)?
Do you have a private and quiet space for your virtual appointments?
Are you comfortable using video conferencing technology?
Do you understand that telehealth is not appropriate for all psychiatric emergencies?
In the event of a psychiatric emergency, are you willing and able to seek in-person care or call emergency services (911)?
Do you understand that medication management via telehealth may require periodic in-person visits or lab work, as determined by your provider?
Do you understand that some medications may require in-person administration or monitoring, and therefore may not be suitable for telehealth?
Do you understand that telehealth services are subject to state and federal regulations, and that your provider may not be able to provide services if you are located in a state where they are not licensed?
Are you aware of the risks and limitations of telehealth, including potential technical difficulties and limitations in physical examination?
Do you have a backup plan if your internet or technology fails during a session?
VIII. Consent and Acknowledgement
I understand that the information provided in this form will be kept confidential and used for the purpose of my care.
I consent to receive psychiatric evaluations and medication management services via telehealth.
I understand the risks and limitations of telehealth, as described above.
I have read and understand the practice's privacy policy and notice of information practices.
I understand that I am responsible for payment of services, regardless of insurance coverage.
Signature:
Thank you for completing this form. We will review your information and contact you to schedule an appointment.
Client Intake Form Insights
Client Intake Form Insights
Please remove this Client Intake Form Insights section before publishing.
Disclaimer: This intake form is for informational purposes only and does not constitute medical advice. The information provided is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
This client intake form is designed to comprehensively gather information necessary for a telehealth psychiatric evaluation and medication management. Here's a detailed breakdown of its insights and purpose:
I. Personal Information:
Purpose: Establishes basic client identity, contact information, and emergency contacts.
Insights:
- Ensures accurate record-keeping and communication.
- Provides a point of contact in case of emergencies.
- Gathers demographic information, which can be relevant for statistical analysis and tailored care.
Importance: Fundamental for patient safety and administrative efficiency.
II. Insurance Information:
Purpose: Collects billing information for insurance claims.
Insights:
- Determines financial responsibility and streamlines the billing process.
- Allows the provider to verify insurance coverage and benefits.
Importance: Crucial for financial viability of the practice and patient access to care.
III. Reason for Seeking Services:
Purpose: Identifies the client's presenting problems, history of mental health treatment, and potential risk factors.
Insights:
- Provides a preliminary understanding of the client's mental health concerns.
- Reveals past treatment experiences, which can inform current treatment planning.
- Uncovers potential risk factors, such as suicidal ideation or history of hospitalization.
Importance: Essential for clinical assessment and risk management. This section is very important for the provider to begin to understand the client.
IV. Medical History:
Purpose: Gathers information about the client's physical health, which can interact with mental health conditions and medications.
Insights:
- Identifies potential medical causes or contributors to mental health symptoms.
- Reveals potential medication interactions or contraindications.
- Helps determine the need for collaboration with the client's primary care physician.
Importance: Vital for safe and effective medication management and holistic care.
V. Psychiatric Evaluations:
Purpose: Allows the client to indicate the specific types of evaluations they are seeking.
Insights:
- Helps the provider understand the client's self-identified needs.
- Streamlines the evaluation process by focusing on relevant areas.
- Allows the client to feel heard, and have input into their care.
Importance: Facilitates targeted assessment and treatment planning.
VI. Medication Management:
Purpose: Gathers information about the client's past and current medication use, and introduces potential medication options.
Insights:
- Reveals medication history, including effectiveness and side effects.
- Allows the provider to assess the client's understanding of medication management.
- Provides a starting point for medication discussions.
Importance: Essential for safe and effective medication management. The inclusion of potential medications is helpful for the client to begin to think about what options are available.
VII. Telehealth Suitability:
Purpose: Assesses the client's access to technology, privacy, and understanding of the limitations of telehealth.
Insights:
- Determines the client's ability to participate in virtual appointments.
- Identifies potential barriers to telehealth, such as lack of internet access or privacy.
- Ensures the client understands the limitations and risks of telehealth.
Importance: Crucial for ensuring the appropriateness and effectiveness of telehealth services. This section is very important for the provider to ensure that the client understands the limitations of telehealth.
VIII. Consent and Acknowledgement:
Purpose: Obtains the client's informed consent for treatment and confirms their understanding of the practice's policies.
Insights:
- Ensures that the client has been informed about the risks and benefits of treatment.
- Documents the client's consent for treatment and release of information.
- Protects the provider from liability.
Importance: Essential for ethical and legal compliance.
Overall Insights:
- Comprehensive Data Collection: The form aims to gather a wide range of information to provide a holistic view of the client's mental health and physical health.
- Risk Assessment: The form includes questions designed to identify potential risk factors, such as suicidal ideation or substance use.
- Informed Consent: The form emphasizes the importance of informed consent and ensures that the client understands the limitations of telehealth.
- Efficiency: The form streamlines the intake process by gathering essential information before the initial appointment.
- Clarity: The form uses clear and concise language to ensure that clients can easily understand the questions.
This detailed intake form is a valuable tool for telehealth providers to gather essential information, assess client suitability, and provide safe and effective psychiatric care.
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