New Patient Registration Form
Please answer the following questions. The first few are screening questions, and the rest are required demographic and insurance questions. Thanks for considering us for your mental health needs.
Are you looking only for counseling/therapy services in Hilliard or Gahanna?
Do you have an insurance deductible for mental health services?
Is this new patient request solely for alcohol and/or drug treatment?
NOTE - none of our providers are equipped to deal with substance addiction problems.
Is this treatment court-ordered or recommended?
NOTE - we do not do court-ordered or recommended treatment and will not provide documentation to the court in legal cases routinely.
Are there legal proceedings, custody disputes, charges, or lawsuits (now or in the near future) that would require involvement or opinions of PFHL providers or staff?
NOTE - we DO NOT handle custody or legal cases, and will not provide documentation to the court in legal cases routinely.
Are you 55-years-old or older?
NOTE - We do not accept patients over the age of 55.
Is your insurance funded by Medicaid or Medicare? This includes all Medicare plans and all Medicaid plans (including CareSource Medicaid, UHC Medicaid, "paper" Medicaid, Buckeye, Molina, etc.)
NOTE - we do not accept any form of Medicaid or Medicare as primary insurance.
Are you currently prescribed a benzodiazepine (Ativan, Xanax, Valium, Klonopin, etc.) and wish to continue this medication?
NOTE - we do NOT prescribe any benzodiazepines in our practice and, if seen, other alternatives will be recommended.
Are you currently prescribed an injected medication (Risperdal Consta, Abilify Maintena, Haldol decanoate, Zyprexa Relprevv, Prolixin, Invega Sustenna, Invega Trinza, Vivitrol, etc.), and wish to continue this medication?
NOTE - we do NOT give injections in our office, and, if seen, other alternatives will be recommended OR your PCP should be contacted in advance to arrange getting the injection after receiving a prescription from our office.
Are you currently off work on mental health disability or seeking disability?
NOTE - we do NOT complete disability forms and do not write patients off work for mental health reasons.
Are you seeking a stimulant (Concerta, Vyvanse, Adderall, Ritalin, etc.) for ADHD?
NOTE - we require ADHD testing by our office that confirms an ADHD diagnosis as well as completion of our CBT for ADHD Skills Group prior to prescribing stimulants. When testing with our office, an intake appointment is required followed by a referral to testing (if appropriate), referral to the CBT for ADHD Skills Group, and finally a meeting with a medical professional to discuss test results and further steps. This process can take between 6 and 8 weeks to complete before medications are received. If testing was done elsewhere within the past 3 years, we find that it is rarely thorough enough for us to accept it, but we will review it to make a determination if it is presented at the initial intake appointment. Be prepared to be retested by our office in most cases and beware that most patients cannot receive ADHD medications for several weeks until the process is complete.
Referral Source
Your answer
Service(s) Requested:
You may choose as many as you need.
Required
Location(s) Preferred:
You may choose as many as you are willing to consider.
Required
Patient First Name:
Your answer
Preferred Name:
Your answer
Patient Last Name:
Your answer
Patient Sex:
Your answer
Patient Date of Birth:
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Parent/Guardian Name (if patient is a minor):
Mobile/Cell Phone:
Your answer
Email Address:
Your answer
Home Phone:
Your answer
Work Phone:
Your answer
Preferred Method of Communication:
Patient Street Address:
Your answer
Patient City:
Your answer
Patient State:
Patient Zip Code:
Your answer
Primary Insurance Company
Select your insurance company from the list below. If not found here, please choose "Other" and type the name. We are in network with the insurances listed below, but are likely out of network for other insurances. We do NOT accept any form of Medicaid or Medicare.
Insurance Phone Number for Mental Health Authorization/Questions:
Your answer
Insurance ID Number:
Your answer
Insurance Group Number:
Your answer
Relationship of Patient to Insurance Subscriber:
NOTE - the subscriber is the person who purchased the insurance policy
Primary Insurance Subscriber Employer:
Your answer
Subscriber Name:
Your answer
Insurance Subscriber Date of Birth:
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YYYY
Secondary Insurance Company
Select your insurance company from the list below. If not found here, please choose "Other" and type the name. We are in network with the insurances listed below, but are likely out of network for other insurances. We do NOT accept any form of Medicaid or Medicare.
Secondary Insurance Phone Number for Mental Health Authorization/Questions:
Your answer
Secondary Insurance ID Number:
Your answer
Secondary Insurance Group Number:
Your answer
Relationship of Patient to Secondary Insurance Subscriber:
NOTE - the subscriber is the person who purchased the insurance policy
Secondary Insurance Subscriber Employer:
Your answer
Secondary Insurance Subscriber Name:
Your answer
Secondary Insurance Subscriber Date of Birth:
MM
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Name of Person Responsible for Payment:
Patient Relationship to Person Responsible for Payment:
Street Address of Person Responsible for Payment:
Your answer
City Where Person Responsible for Payment Lives:
Your answer
State Where Person Responsible for Payment Lives:
Zip Code Where Person Responsible for Payment Lives:
Your answer
Date of Birth of Person Responsible for Payment:
MM
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DD
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YYYY
Sex of Person Responsible for Payment:
Your answer
Phone Number of Person Responsible for Payment:
Your answer
Next of Kin/Emergency Contact Name:
Your answer
Relationship of Emergency Contact to Patient:
Phone Number of Emergency Contact/Next of Kin
Your answer
Street Address of Emergency Contact/Next of Kin
Your answer
City Where Emergency Contact/Next of Kin Lives:
Your answer
State Where Emergency Contact/Next of Kin Lives:
Zip Code Where Emergency Contact/Next of Kin Lives:
Your answer
Reason for Appointment/Referral:
Please be as specific as possible and include previous diagnoses and current medications, if any.
Your answer
If this new patient request is for a child under the age of 18, are the parents separated or divorced OR does the child reside with someone other than a biological parent (guardian, parent, grandparent, etc.)?
All patients under the age of 18 whose parents are separated, divorced, or living with a nonbiological parent MUST have written authorization by both parents (or the custodial parent, if a legal agreement exists) before treatment can be provided. Please indicate below that you agree to bring written documentation to the first appointment authorizing treatment (or a legal agreement, such as a divorce decree) that authorizes the parent present to make those decisions, or understand that your child can't be seen if this document isn't provided.
I understand that PFHL providers DO NOT provide legal documentation, opinions, or consultations, and certify that the patient named above is in no way involved in any current (or near future) legal proceedings, lawsuits, or custody hearings that might involve PFHL providers or staff.
I acknowledge that missing my initial appointment will result in immediate dismissal and case closure and I will not be allowed to reschedule another appointment. I further agree to pay an initial no show fee of $150 if I miss my initial appointment.
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