New Patient Form

New Patient Form | Active

What is the patient's name?

First Name

Last Name

Is the patient an adult or a child?

Adult

Child

It's nice to meet you, !

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When was the patient born?

Birthdate

What is the patient’s Social Security number?
(You can also provide this later if you’re not comfortable sharing it now.)

Social Security Number

A person’s race and sex can affect how their body responds to medications.

This next section asks for that information to help guide your care.

How can we reach you?

Patient's phone number

Patient's home address

Address

Address Line

City

State

Zip Code

Who should we contact in case of an emergency?

Emergency contact

Emergency Contact Number

Do you have a preferred pharmacy?

Feel free to skip this question if you don’t!

Pharmacy Name and Address

It’s very important that we get a thorough mental health history to better understand your needs and provide the most effective care.

This information helps us tailor treatment to you and ensures nothing important is overlooked.

Please describe what the main problem is and any stressors that may be contributing to the problem:

When did the problem start?

Has the patient seen a psychiatrist before? If yes, please list their name, location, and the approximate dates of treatment.

Has the patient ever been admitted to a psychiatric hospital? If yes, please provide the name of the hospital, when the admission occurred, how long they stayed, and the reason for the admission.

Which psychiatric medications has the patient taken in the past? Please list each one and describe how the patient responded to it (positive effects, side effects, or no change).

What psychiatric or medical medications is the patient currently taking? Please include any prescriptions, over-the-counter drugs, vitamins, or herbal supplements.

Has the patient ever experienced suicidal or homicidal thoughts? If yes, please include when it occurred, whether there was a plan, and any treatment received.

Has the patient ever had psychotherapy? If yes, please list when it took place, how long it lasted, and the name of the therapist (if known).

Is there any family history of mental health conditions such as depression, anxiety, bipolar disorder, schizophrenia, learning disabilities, ADHD/ADD, sleep issues, or movement disorders? If yes, please list the family member and their diagnosis.

Is there any family history of suicide attempts or completed suicide? If yes, please list who and their relationship to the patient.

Has the patient experienced any significant childhood trauma? If you're comfortable, please share any details you feel are important for us to know.

We also need to ask about any other medical history that could affect your mental health.

Understanding your overall health helps us provide more complete and effective care.

Past Medical history

Please list any current or past medical conditions and any surgeries the patient has had.

Has the patient had a history of seizures?

Yes

Has the patient had a history of head trauma?

Yes

Has the patient had a history of heart problems?

Yes

Any allergies to medications? Please list the medication(s) and the reaction to each.

Has the patient used any illegal drugs, including marijuana? If yes, please share the age of first use, how often it was used, the last time it was used, and any problems it caused.

Next, these questions help us screen for topics your provider might want to address during your visit.

GAD-7 QUESTIONNAIRE

Instructions: CHECK the answer that best applies to you. Please answer each question as best you can.

Over the last 2 weeks, how often have you been bothered by the following problems?

	Not at all (0)	Several Days (1)	More than half the days (2)	Nearly everyday (3)
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritated
7. Feeling afraid as if something awful might happen

8. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

PHQ-9 QUESTIONNAIRE

Instructions: CHECK the answer that best applies to you. Please answer each question as best you can.

Over the last 2 weeks, how often have you been bothered by the following problems?

	Not at all (0)	Several Days (1)	More than half the days (2)	Nearly everyday (3)
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling or staying asleep, or sleeping too much.
4. Trouble relaxing
5. Poor appetite or over eating.
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down.
7. Trouble concentrating on things, such as reading the newspaper or watching television.
8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead, or of hurting yourself.

10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Adult ADHD Self-Assessment

Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during your appointment.

	Never	Rarely	Sometimes	Often	Very often
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

How old were you when these problems first began to occur?

Next, we’ll be asking about your relationships, education, work, and legal history.

These questions help us understand your life experiences and how they may affect your mental health and well-being.

Relationship status

Who lives with the patient? Please include any children and their ages.

What is the highest level of education the patient has completed?

How would you describe the patient’s academic performance in school?

Employment history: Please list the patient’s current job and the last two jobs if the current one has been held for less than a year.

Legal history: Please list any past offenses and the year they occurred.

Consent to Use Electronic Communications

Consent to Use Electronic Communications

Top Tier Psychiatry offers the following ways to communicate electronically:

Email
Video calls (e.g., Skype®, FaceTime®, Zoom®, Google Meet®)
Patient portal or website
Text message appointment reminders
Secure text messages through RingCentral

Risks of Electronic Communication
While we take reasonable steps to protect your privacy, electronic communication has some risks:

Messages can be misdirected, intercepted, or altered.
Some tools may be more open to third-party access.
Employers or service providers may view or store communications.
Deleted messages may still be stored in backups.
Communications could be required by law (e.g., court order).
Malware or disruptions may affect your system.

Additional Risks for Email & Text

Messages may go to the wrong person.
It’s easier to fake or tamper with messages.
The sender’s identity isn’t always guaranteed.

Conditions for Use

Electronic messages may not get immediate replies. For urgent matters, call or visit in person.
Follow up if you don’t get a response in a reasonable time.
These tools do not replace in-person care.
Communication may be added to your medical record.
Your information may be shared only with authorized staff.

Sensitive Information
We ask that you avoid discussing sensitive medical topics electronically unless approved. You may request limits on what is shared this way.

Tips for Use

Don’t use work computers or shared devices.
Let us know if your contact info changes.
Use clear subject lines and include all needed details in your messages.

Patient Acknowledgment and Agreement
I have read and understand the risks, limits, and instructions for using electronic communication with Top Tier Psychiatry. I accept these terms and understand that:

Not all electronic messages may be encrypted.
The clinic may stop using electronic communication at any time with written notice.

Statements and Disclosures

Confidentiality Statement

We keep records of the care we provide. The patient or their authorized representative may view these records at any time. While the records belong to us, the information in them belongs to you.

If you want us to share your information with someone else, you’ll need to sign a consent form and may be responsible for any fees.

What you discuss with your provider is private and confidential. However, we may be required to share information without your consent in certain situations, including:

If there’s a risk of harm to yourself or others
Suspected abuse or neglect of a child or elderly person
Court-ordered cases related to child custody

Trainees and Learners Disclosure

At times, Top Tier Psychiatry may have students or trainees as part of our care team. They follow the same privacy and confidentiality rules as all of our providers.

When you receive care at our clinic:

Students may access your medical records for learning purposes unless you choose to opt out.
You may be asked if a student can sit in during your visit. You can say yes or no at any time.
You may also be asked if a student can take part in your interview or care. You can decline this at any time.

Saying no to student access or participation will not affect your ability to get care or the quality of care you receive.

Additional Disclaimers

Redisclosure:
I understand that once my health information is shared, the recipient may disclose it to others. My healthcare provider cannot guarantee that the recipient will protect my information under the same laws.

Voluntary:
I understand that signing this form is completely voluntary.

Right to Revoke:
I may change my mind at any time and cancel this authorization by giving written notice. The cancellation will take effect once my provider receives it. It will not affect any actions already taken based on my earlier permission.

Authorization to Release Medical Information

To help coordinate my care and process insurance claims, I authorize the release of my health information. This includes details about my medical history, mental or physical health, and any treatment I have received.

I authorize the use or disclosure of the following health information: (Please check one)

All of my health information

My health information covering only the following conditions / period (detail below)

If selecting partial disclosure, please specify what information may be shared and the time period it covers:

I have read and agree to the terms outlined above. By checking this box, I confirm my agreement in place of a signature.

Notice of Legal Representation and Services

Notice of Legal Representation and Services

Providers at Top Tier Psychiatry do not offer legal evaluations or provide professional testimony for legal matters. If a provider is subpoenaed, the patient or their representative is responsible for all related costs.

Please note:
- Insurance does not cover legal testimony or depositions.
- The fee is $1,000 per hour, with a two-hour minimum, and will be scheduled at the provider’s discretion for time, date, and location.
- Financial arrangements must be made in advance if this situation arises.
Additionally, insurance does not cover administrative fees for certified documents such as:
- Work excuses
- Disability/medical leave forms
- Other official paperwork
These requests are subject to:
- A $250–$500 fee per request, based on the time required
- An additional $0.25 per page for physical copies, plus mailing costs if applicable

Full Name of Patient / Authorized Representative (By e-signing, you confirm that you have read, understood, and agree to the Notice of Legal Representation and Services.)

Consent to Treatment and Controlled Substances Agreement

Consent to Treatment

I voluntarily agree to receive mental health services from Top Tier Psychiatry. These services may include evaluation, diagnosis, therapy, and medication management. I understand that I can ask questions at any time and have the right to accept or refuse any part of my treatment.

I understand that once services begin, I may withdraw my consent at any time. If I have concerns about my treatment or progress, I will make every effort to discuss them with my provider before discontinuing care.

I consent to Top Tier Psychiatry obtaining my medical records from relevant sources—such as other clinics, pharmacies, and state or federal databases—to support my treatment.

I understand that medications may have potential risks, benefits, and side effects. These will be discussed during my treatment session, and I agree to take medications as prescribed with full awareness of these factors.

If the patient is a minor:
By signing below, I confirm that I am the authorized parent or legal guardian and I give my consent for the minor patient to receive treatment through Top Tier Psychiatry.

Controlled Substances Agreement

Certain medications like benzodiazepines, non-benzodiazepine sleep aids, and stimulants can be helpful for treating mental health conditions. However, they have a high risk for misuse and are strictly monitored by local, state, and federal laws. These medications are meant to reduce symptoms and improve daily functioning and quality of life.

If my provider determines that a controlled substance is appropriate for my care, I agree to the following:

Prescription History
I give permission for Top Tier Psychiatry to access my full prescription history when needed. This helps support safe and effective treatment. I understand this may include sensitive information, and I trust it will be handled with care and confidentiality.

Treatment Goals
I understand the goal of treatment is to manage my symptoms and improve my well-being. Since I’m receiving a strong medication, I agree to support my own care by:

Staying active and exercising regularly
Maintaining a healthy weight
Avoiding tobacco and alcohol
Attending psychotherapy if recommended
Following my provider’s treatment plan

Patient Responsibility and Agreement

I am responsible for the controlled substance medications prescribed to me. If my prescription is lost, stolen, misplaced, or used up early, I understand it will not be replaced.

I give permission for my provider to share my diagnosis and treatment details with other healthcare providers and pharmacists involved in my care. This includes sharing a copy of this agreement to support coordination and accountability.

I will use only one pharmacy for all my prescription refills and will provide the name and phone number to Top Tier Psychiatry. Exceptions may be made for non-controlled medications while traveling.

I understand that I may not be allowed to drive while taking controlled substance medications. It is my responsibility to follow all state laws related to driving while on these medications.

I will not request or accept the same or similar controlled medications from any other provider while receiving treatment from Top Tier Psychiatry. I will not give, share, or sell my medications to anyone.

I understand that controlled substance refills will not be given if I run out early, lose a prescription, spill or misplace my medication, or if it is stolen. I am responsible for taking the medication exactly as prescribed, keeping track of how much I have left, and storing it safely to prevent theft.

I have read and agree to the terms outlined above. By checking this box, I confirm my agreement in place of a signature.

Provision of Telemedicine Services and Its Limitations

Provision of Telemedicine Services

I understand that, in addition to in-person care, Top Tier Psychiatry offers telemedicine services when appropriate under state and federal law. These services are provided for convenience, personal preference, or to support patients with physical or mental impairments that may limit in-person visits. I understand that Top Tier Psychiatry and its providers will make the final decision about whether telemedicine is suitable for me at any point in my care.

Limitations of Telemedicine Services

I understand that, while telemedicine can be a convenient way to receive care, it may limit certain physical and social cues that help with assessment, diagnosis, and treatment. By agreeing to telemedicine appointments, I accept both the benefits and limitations of this type of care.

Cancellation Policy and Medication Refill Policy

Cancellation Policy

If you need to cancel your appointment, you must do so at least 48 hours in advance.

To cancel or reschedule, you must speak directly with a staff member by calling the clinic.
Voicemail messages will not be accepted and will be treated as a No Call / No Show.

A $50 fee will be charged for:

Appointments canceled with less than 24 hours’ notice
Any No Call / No Show

This fee must be paid at your next visit. There are no exceptions to this policy.

You are responsible for keeping track of your scheduled appointment date and time.

Medication Refill Policy

Medication refills can be requested at any time, but they will only be sent to the pharmacy during normal business hours.

It is the patient’s responsibility to take medications exactly as prescribed by their provider.

Mental Health Crisis Policy

During a Mental Health Crisis

Top Tier Psychiatry provides only outpatient care and does not offer services during mental health crises.

If you are experiencing a mental health crisis, please:

Call 9-1-1
Go to the nearest emergency department

If a patient contacts Top Tier Psychiatry during a mental health crisis, our staff will direct the patient to call 9-1-1 or visit the nearest emergency department for immediate assistance.

After a Mental Health Crisis

Once a patient has recovered and been stabilized after a mental health crisis at an emergency department or acute care facility, they must notify Top Tier Psychiatry as soon as possible.

It is the patient’s responsibility to inform Top Tier Psychiatry providers of any recent hospital admissions related to mental health.

Important Action Steps

In the event of a mental health crisis, patients or patient representatives should:

Dial 9-1-1 and request a CIT (Crisis Intervention Team) from the dispatcher
Go to the nearest emergency department
Dial 9-8-8 to reach the National Suicide Prevention Lifeline, if applicable

I have read and agree to the terms outlined above. By checking this box, I confirm my agreement in place of a signature.

Will you be using insurance for your care?

Yes, using insurance

No, I will not be using insurance

Financial Responsibility, Authorization, and Assignment of Benefits Agreement

Medical Information Release
I give Top Tier Psychiatry permission to share my medical information with my insurance company or a designated attorney for billing and review purposes. This permission stays in effect until I cancel it in writing. I understand I can ask for a copy of this authorization.
Assignment of Insurance Benefits
I allow Top Tier Psychiatry to receive payment directly from my insurance for services provided. Any money paid beyond what I owe will be credited to my account. I understand I’m still responsible for any charges not covered by my insurance.
My Financial Responsibility
I agree to pay any amounts not covered by my insurance. If I don’t pay, I may be responsible for collections, court costs, and legal fees.
Keeping Insurance Info Updated
I must provide a valid photo ID and current insurance information. If my insurance changes, I must tell Top Tier Psychiatry right away. If I give outdated insurance info and it’s past the filing deadline, I will be responsible for the charges.
Claim Submission
The Clinic will submit claims and help with the process, but I’m still responsible if delays or denials happen due to missing info from me or my insurance.
Payments and Fees
All co-pays, deductibles, co-insurance, cancellation fees, and any relevant collectible amounts must be paid before my appointment. A $50 fee applies for missed appointments or cancellations with less than 48 hours’ notice. If payment isn’t made at least two hours before my appointment, it will be canceled and must be rescheduled.
Cost Estimates
Cost estimates are available on request, but final amounts depend on what insurance pays or may be based on direct-pay rates which will be communicated in adv. An estimate is not a final bill.
Non-Covered Services
I understand I’m responsible for services my insurance does not cover, is out-of-network, or is considered not medically necessary. The Clinic will try to verify benefits, but it’s my job to know my coverage.
Insurance Billing Limits
I allow Top Tier Psychiatry to bill my insurance for services provided. The Clinic will only bill my primary insurance. I’m responsible for submitting to secondary insurance, except when Medicare is primary or Medicaid is secondary.
Overall Financial Obligation
I agree to be responsible for all charges not paid by insurance. If I don’t follow through with payments, I agree to cover any attorney or collection fees.
Credit Card on File Policy
Due to insurance changes, patients now pay more out-of-pocket. We keep a credit/debit card on file to cover co-pays, deductibles, co-insurance, and cancellation fees.

We keep card information secure and private. The card will be charged after insurance has paid its share and told us what you owe. If your card is declined or expired, you’ll have 30 days to update it before the account is sent to collections.

I give permission for the Clinic to save and charge my card for any balances I owe. If my card changes or expires, I agree to provide a new one and allow it to be charged under the same terms.

I have read and agree to the terms outlined above. By checking this box, I confirm my agreement in place of a signature.

Out-of-Pocket Self-Pay Agreement

Services Provided
The Clinic will provide medical services, which may include consultations, treatment, and other care as needed.
Payment Terms
The Patient agrees to pay the full cost of services out-of-pocket at the time of the appointment. Prices vary by location and market rates, which staff can provide. The Clinic does not bill insurance for self-pay services. The Patient is responsible for all charges.
Payment Method
The Patient agrees to keep a valid credit or debit card on file. This card will be charged for all visits and related fees. The Patient is responsible for updating card information as needed.
Missed Appointments
Missed appointments or cancellations made less than 48 hours in advance may result in a $50 fee, which will be charged to the card on file.
Refunds
All payments are non-refundable. Any concerns about charges must be reported within 30 days.

Confidentiality
The Clinic will keep all credit/debit card information private and secure.
Ending This Agreement
Either the Patient or the Clinic may end this agreement with written notice. The Patient is still responsible for any unpaid charges.
Legal
This agreement follows the laws of the state where the Clinic is located.
Entire Agreement
This document is the full agreement. Any changes must be in writing and signed by both parties.
Card on File Authorization
The card on file will be used to pay for any patient costs, including copays, deductibles, or co-insurance. If the card is declined or expired, the appointment may need to be rescheduled. The Patient agrees to provide an updated card if needed, and authorizes the Clinic to save and charge the new card as with the original.

Please upload a picture of the FRONT of your credit card

File Upload

Choose File

Please upload a picture of the BACK of your credit card

File Upload

Choose File

I have read and agree to the terms outlined above. By checking this box, I confirm my agreement in place of a signature.

New Patient Form

It's nice to meet you, !Let's keep going.

Consent to Use Electronic Communications

Statements and Disclosures

Notice of Legal Representation and Services

Consent to Treatment and Controlled Substances Agreement

Provision of Telemedicine Services and Its Limitations

Cancellation Policy and Medication Refill Policy

Mental Health Crisis Policy

Will you be using insurance for your care?

Financial Responsibility, Authorization, and Assignment of Benefits Agreement

Out-of-Pocket Self-Pay Agreement

It's nice to meet you, !

Let's keep going.