NEW PATIENT INTAKE FORM PATIENT INFORMATION (ADULT) Patient’s First Name * First Middle Initial MI Last Name * Last Gender * Select Male Female Date of Birth: * Social Security Number (Optional) Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal PATIENT INFORMATION (CHILD) PLEASE FILL IF PATIENT IS A CHILD: CHILD’S NAME: Full Name Date of Birth: Age: Person Providing the Information: Full Name Today’s Date * Sex: * Select Male Female Please describe reason for evaluation: Which services are you requesting? * Primary Care Services Psychiatric Mental Health Counselor Psychosocial Rehabilitation Services Targeted Case Management Please list diagnosis, if any, who diagnosed, and when your child was diagnosed: PARENT / LEGAL GUARDIAN First Name Parent | Legal Guardian First Name/Middle Name Last Name Parent | Legal Guardian Last Name Relation to Client Relation to Client Phone Email REFERRING SOURCE Physician Full Name Full Name Phone Fax INSURANCE *** MUST BE FILL *** PRIMARY INSURANCE * PHONE POLICY NUMBER * GROUP POLICY HOLDER * RELATION TO PATIENT POLICY HOLDER’S DAY OF BIRTH POLICY HOLDER’S SS# POLICY HOLDER’S EMPLOYER REASON FOR REFERRAL | DIAGNOSTIC SECONDARY INSURANCE PHONE POLICY NUMBER GROUP POLICY HOLDER RELATION TO PATIENT POLICY HOLDER’S DAY OF BIRTH POLICY HOLDER’S SS# POLICY HOLDER’S EMPLOYER REASON FOR REFERRAL | DIAGNOSTIC YOUR HEALTH CARE PROVIDER, INSURER, OR PLAN MAY REQUIRE A PHYSICIAN REFERRAL OR PRIOR AUTHORIZATION AND YOU MAY BE OBLIGATED FOR PARTIAL OR FULL PAYMENT FOR SERVICES PROVIDED. INSURED OR AUTHORIZED PERSON’S SIGNATURE: PATIENT INSURED SIGNATURE * Clear Date * AUTHORIZATION TO RELEASE/OBTAIN CONFIDENTIAL INFORMATION PATIENT SIGNATURE * Clear I hereby authorize the release of any necessary information to process insurance claims, including medical and billing information, as well as to discuss the child’s case information with other Therapists working within the building structure of Carrousel Health Care Corporation to/from, from/to the referring physician, Therapist Co-workers and insurance company. Name Name First First Last Last Date * PATIENT CONSENT OF SERVICE AGREEMENT I consent that treatment will be rendered at the following locations. * Office School Home Telehealth NAME OF PATIENT * Date of Birth * PRINT NAME PARENT/LEGAL GUARDIAN Date * Patient Service Agreement between below “Parent/Legal Guardian” and “Therapy” * Clear SIGNATURE: PARENT/LEGAL GUARDIAN New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations I, * ( the term “I” refers to the Parent/Legal Guardian of child) understand that as part of my healthcare, “Carrousel Health Care Corporation,” originates and maintains paper and/or electronic records describing “my” (the term “my” refers to parent and/or child) health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care of treatment. I understand that this information serves as: -A basis for planning my care and treatment, -A means of communication among the many health professionals who contributes to my care, -A source of information for applying my diagnosis and surgical information to my bill, -A means by which a third-party payer can verify that services billed were actually provided, and -A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcareprofessionals. I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: -The right to review the notice prior to signing this consent, -The right to object to the use of my health information for directory purposes, and -The right to request restrictions as to how my health information may be used or disclosed to carry out treatment,payment, or healthcare operations. I understand that “Therapy,” is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that “Therapy,” reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should “Therapy,” change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or if I agree e-mail). I wish to have the following restrictions to the use or disclose of my health information: I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via text, fax and/or e-mail. I fully understand and accept the terms of this consent. * Clear Parent/legal Guardian’s Signature Date * Credit Card Agreement All parents and guardians are responsible for paying their child’s co pay and deductibles, set by their Insurance Company. These fees are nonnegotiable. Unless otherwise specified, we will collect these fees every session. We have made this process easier by accepting Visa card, Master card, American Express card, and Discover card. By signing below it is agreed that your credit card number will remain on file and “Carrousel Health Care Corporation” will charge that credit card only in the event that your child attends his or her therapy session. A receipt will be provided to you for all charges applied. We hope this makes everything easier for you to keep track of your fees. Thank you, Patient/Parent/Guardian Name (Printed) Title Patient/Parent/Guardian Signature Clear Date Credit Card # MC/Visa/American/Discover Expiration Date HIPPA Release Form Parent/Guardian of Patient: * I, give permission to “CARROUSEL HEALTH CARE CORPORATION.” and all employees to discuss and/or receive medical information including medical records concerning any and all aspects of patient’s previous healthcare by a doctor, physical, occupational or speech therapist, or other medical professional. This release is required to obtain medical information according to the privacy rule detailed in HIPPA (The Health Insurance Portability and Accountability Act of 1996). Patient Name: * Patient Date of Birth: * Patient’s Social Security: Parent/Guardian’s Signature: * Clear Date * COVID-19 PATIENT SCREENING FORM 1. Do you have fever or have you felt hot or feverish recently? Yes No 2. Do you have a dry cough? Yes No 3. Have you experienced shortness of breath or other difficulties breathing? Yes No 4. Do you have a runny nose? Yes No 5. Do you have any recent onset of headache or sore thoat? Yes No 6. Do you have muscle pain? Yes No 7. Do you have flu-like symptoms, such as gastrointestinal upset, headache or fatigue? Yes No 8. Have you recently lost or had a reduction in your sense of taste or smell? Yes No 9. Have you been in contact with someone that have tested positive for COVID-19? Yes No 10. Have you tested positive for COVID-19? Yes No 11. Are you over the age of 65? Yes No 12. Do you have heart disease, lung disease, kidney disease diabetes or any auto-immune disorders? Yes No Hamilton Anxiety Rating Scale (HAM-A) Patient Name * Patient Name First First Last Last Date * Bellow is a list of phrases that describe certain feeling that people have. Please select one of the five responses for each of the 14 questions. 0 = Not Present 1 = Mild 2 = Moderate 3 = Severe 4 = Very Severe 1. Anxious Mood * 0 1 2 3 4 Worries, anticipation, of the words, fearful anticipation, irritability. 2. Tension * 0 1 2 3 4 Feeling of tension, fatiguability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax. 3. Fears * 0 1 2 3 4 Of dark, of strangers, of being alone, of animals, of trafic, of crowds. 4. Insomnia * 0 1 2 3 4 Difficulty in falling to asleep, broken sleep, unsatisfying sleep, and fatigue on walking, dreams, nightmares, night terrors. 5. Intellectual * 0 1 2 3 4 Difficulty in concentration, poor memory 6. Depressed Mood * 0 1 2 3 4 Loss of interest, lack of pleasure in hobbies, depression, early walking, diurnal swing. 7. Somatic(muscular) * 0 1 2 3 4 Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone. 8. Somatic(sensory) * 0 1 2 3 4 Tinnitus, blurring of vision, hot and cold flashes, feeling of weakness, pricking sensation. 9. Cardiovascular Symptoms * 0 1 2 3 4 Tachycardia, palpitations pain in chest, throbbing of vessels, fainting feelings, missing beats. 10. Respiratory Symptoms * 0 1 2 3 4 Pressure or constriction in chest, choking feeling, sighing, dyspnea. 11. Gastrointestinal Symptoms * 0 1 2 3 4 Difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation. 12. Genitourinary Symptoms * 0 1 2 3 4 Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence. 13. Autonomic Symptoms * 0 1 2 3 4 Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension, headache, raising of hair. 14. Behavior at Interview * 0 1 2 3 4 Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc. 0 = Not Present 1 = Mild 2 = Moderate 3 = Severe 4 = Very Severe Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where <17 indicates mild severity, 18–24 mild to moderate severity and 25–30 moderate to severe. 121234567891011 : 0030 AMPM time Patient Depression Questionnaire (PHQ-9) Patient ID: Date * Patient Name * Patient Name First First Last Last Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things * Please select one Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 2. Feeling down, depressed, or hopeless * Please select one Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 3. Trouble falling or staying asleep, or sleeping to much * Please select one Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 4. Feeling tired or having little energy * Please select one Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 5. Poor appetite or overeating * Please select one Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 6. Feeling bad about yourself, or that you are a failure, or have let yourself or your family down * Please select one Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 7. Trouble concentrating or things, such as reading the newspaper or watching television * Please select one Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 8. Moving or speaking so slowly that other people could notice, or the opposite (moving a lot more that normal) * Please select one Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 9. Thoughts that you would be better off dead, or of hurting yourself * Please select one Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) Scare: 0-4 Minimal or non Monitor; may not require treatment 5-9 Mild 10-14 Moderate (Use clinical judgment {symptom duration, functional impairment} to determine necessity of treatment) 15-19 Moderate severe 20-27 Severe (Warrants active treatment with psychotherapy, medications, or combination) CRITICAL ACTIONS: Perform suicide risk assessment in patients who respond positively to item 9 “Thoughts that you would be better off dead or of hurting yourself in some way.” Rule out bipolar disorder, normal bereavement, and medical disorders causing depression. * 121234567891011 : 0030 AMPM Time If you are human, leave this field blank. Submit