try U-first Start Today New Patient Form Patient InformationInsurance InformationInsurance InformationClient HistoryFamily History:Consent for TreatmentFINANCIAL AGREEMENTPRIVACY PRACTICESCONSENT FOR MEDICATIONCREDIT CARD “ON FILE ” AUTHORIZATIONCONSENT & AUTHORIZATION TO RELEASE INFORMATIONPatient Health QuestionnaireScreen VersionADHD Assessment for Children Client Confidential Information FormToday's DateLast Name :First Name :Middle Initial:Age:Date of Birth:Gender: M F TMarital Status:How long: Race:Address: City:State :Zip Code :Cell Phone:Work Phone:Home Phone:Email :May we leave voice mail? Yes NoMay we leave text message? Yes NoMay we leave email? Yes NoMay we send you a portal invitation? Yes NoRefereed by:Employer/School:Occupation / Grade:Emergency Contact:Relationship:Phone :Email address :PreviousNextInsurance InformationInsurance Company :Name of Insured:Insured Date of Birth :Relationship of Insured :Holder DOB :Social Security # Policy #Group #Policy Holder:Co-Pay: $Deductible: $Address (if different) :City :State :zip :Please attach a copy of your state picture identification AND a copy of your insurance card here. If not,please attach under the messaging tab in the Patient Ally Portal, via our secure email address at: info@ufirsthealthcare.org OR attach under the Book Appointment tab on our web site at :www.ufirsthealthcare.org for any difficulties, please call our office: 833-583-4778. INSURANCE AUTHORIZATION AND ASSIGNMENT: I understand that I am responsible for all charges ncurred by me and all charges not allowed by my insurance company. I authorize the release of medical information necessary to process my claims. I authorize payment of any assigned medical benefits to my provider directly.DateFront ID Card :Choose File Back ID Card :Choose File Front Insurance Card :Choose File Back Insurance Card :Choose File PreviousNextLegal Representative of PatientLegal Representative Last Name:Middle Name :First Name :Relationship : CHILD SPOUSE GUARDIAN HEALTH CARE POA SELFAddress :City :State :Zip Code :Phone :Email :PreviousNextClient HistoryHeight :Weight :Primary Care Provider :Last Physical Exam: Current/Previous Psychiatric Provider:Pharmacy:City:Zip code:Phone:Any reason you may be pregnant?LMP:Chief Complaint:Please tell us the REASON FOR TODAY’S VISIT or any special concerns you would like to discuss today :History of symptoms:When did your symptoms start?Describe what it looks like or feels like?Tell us about your support system:Previous Medical History: Heart Problems High Blood Pressure Diabetes Arthritis Gout Seizures Depression Anxiety Cancer Bleeding Disorder Alcoholism Tuberculosis Stomach Ulcers Liver Issues Kidney Issues Lung Disease Drug Abuse Thyroid Disea Anemia Hepatitis Seizures Other:Please explain any other significant medical problems, symptoms, or illnesses:Surgical History : APPENDECTOMY THYROIDECTOMY HERNIA REPAIR SPINAL SURGERY NECK SURGERY CHOLECYSTECTOM COLECTOMY CORONARY BYPASS HYSTERECTOM BREAST SURGERY TUBAL LIGATIO CATARACT SURGERY OTHERHistory of Hospitalizations:(Date, Institution, Reason)Developmental History:(Timely milestones? Alternative schools)Current Previous Psychological Treatment:Trauma: Previous/Current: (Divorce, sexual, physical, emotional, etc.…) Legal Concerns: (Custody, Probation, Parole, Etc.…)Prescription Medications: Name, Date started, Dose, Frequency, Last Date Taken and ReasonAny complaints with your medications:List all non-prescription / herbal or over the counter drugs:Please list ALL allergies to medications , foods and environment below:ALLERGY:TYPE OF REACTION: (i.e., nausea, anxiety)Substance use: Never used any substances: Currently using : Alcohol Caffeine Nicotine Heroin Opiates Marijuana Crack/ Cocaine Methamphetamines Inhalants Stimulants Hallucinogens otherAmount of Use :Frequency of Use :How Long :Used in the past Alcohol Caffeine Nicotine Heroin Opiates Marijuana Crack/ Cocaine Methamphetamines Inhalants Stimulants Hallucinogens otherPreviousNextFamily HistoryMedical:Surgical: Psychiatric:Suicide:Psychiatric Hospitalization:Legal: Domestic violence:Nervous Breakdown:Depression:Anxiety:Substance Abuse: Physical/Sexual abuse:Family Dynamic:Describe relationship with your mother:Describe relationship with your father:Did parents stay married or divorced? If separated or divorced, how old were you and how did it impact you?Primary Parent: Both Father or MotherWere there any other primary care givers who you had a significant relationship with? If so, please describe how this person may have impacted your life:Did you grow up in a home that had family members that abused drugs or alcohol? Yes No# of Siblings:Brothers:Ages:Sisters:Ages:Birth Order :How would you describe your relationship with your siblings:Sex partner?: Male. Female BothHow long in relationship?Relationship satisfaction?Do you have children? Yes No How many?What are their ages?:Describe any problems any of your children are having:Symptoms checklist: What do you have difficulty with?Difficulty: Anxiety Depression Mood changes Anger temper Panic Fears Irritability Headaches Concentration Loss of memory Excessive worry Felling manic Trusting others Communicating with others Drugs /alcohol Impulsivity Frequent vomiting Eating problems Weight loss Weight Gain Blackouts People in general Parents/Siblings Children/ classmate Marriage / partnership Friends Co-worker(s) Employer Finances Legal problems Sexual problems Staying focused History of child abuse Domestic violence Thoughts of hurting self thoughts of hurting others Thoughts of suicide Sleep too much Sleep too little Getting to sleep Staying asleep Nightmares Night terrors Sleep walking Abdominal distress Fainting Dizziness Nausea Diarrhea chest pain shortness of breath Lump in throat Sweating Heart palpitation Muscle tension Pain in joints Allergies Make careless mistakes Frequent fidgeting Speaking without thinking Waiting your turn completing tasks Paying attention HyperactivityAdditional pertinent health concerns:PreviousNextConsent for Treatment| Authorization| Information We welcome you to U-First Healthcare, LLC and we are pleased to be able to support your mental, medical and physical wellness. Our sincere goal is to facilitate your healing, growth, and restoration and to provide you with the maximum benefit from your treatment plan. In order for treatment to be most effective, it is crucial that you take an active role in this journey by working on things that you and your provider discuss at your visit. In addition, avoid any mind-altering substances at least eight hours before your visit. The more of yourself you are willing to invest, the greater the return. Further, it is our policy to only see clients who we believe have the capacity to resolve their own problems with our assistance. It is our intention to empower you in your growth process to the degree that you can face life’s challenges in the future without the practitioners here at U-First Healthcare. Your provider will always keep everything you say completely confidential, following exceptions: (1) You direct your provider by signing a “Release of Information” form or “Coordination of Care” form; (2) your provider determines that you are a danger to yourself or others;(3) you report information about abuse of a child, an elderly person, or a disabled individual; or (4) your provider is ordered by a judge to disclose information. In the latter case, your provider’s license does provide with the ability to uphold what is legally termed “privileged communication” which is your right as a client to have a confidential relationship with behavioral professionals. The state of Georgia has a very good track record in respecting this legal right. If there is such an order, it can be appealed. We cannot guarantee a sustained appeal, but we use every resource to keep what you have said confidential. Please make note that in couples and family counseling, your provider does not agree to keep secrets. Therefore, information revealed in any context may be discussed with either partner. If you choose to include personal and or clinical concerns, please know that your PHI information is at risk, does not guarantee privacy, and is not deemed confidential. Please know U-First Healthcare will maintain your confidentiality to the best of our ability, however, we cannot guarantee this with any electronic communication. Please initial that you have read this information Tele-mental Health Services Tele-mental health services are used when our mental health providers are not physically present with you to evaluate your mental health needs and if appropriate the prescription of medications. You and your mental health provider will utilize HIPAA compliant virtual face- to-face apparatus on a computer, tablet, or cell phone. Tele-mental health services use a video camera and computer to send both voice and visual images between you and your mental health practitioner. Tele-mental health services can be just as beneficial as in person sessions. Since face-to-face treatment is relegated only in the state of Georgia so are virtual tele-mental sessions. Your provider will treat and document your session. Any prescriptions that are prescribed will be sent to the pharmacy and ready for you to pick up. In Case of Emergency U-First Healthcare, LLC is an outpatient practice. We are set up to accommodate individuals who are reasonably safe and resourceful. We do not carry beepers, pagers ;nor are we available at all times. If at any time this does not feel like sufficient support, please inform your provider so additional resources can be discussed or transfer your case to a provider/ clinic with 24-hour availability. Generally, your provider will return messages within 24-48 hours. If you have a mental or medical health emergency, do not wait for a call back, but proceed with one or more of the following:GCAL 800-715-4225 Call Ridgeview Institute at 770-434-4567 or Peachford Hospital at 770-454-5589 Call 911 24hours a day into a psychiatric hospital or emergency room for an assessment Professional Relationship Mental health treatment is a professional service we will provide to you. A provider’s responses to your situation are based onr tested theories and methods of change. Because of the nature of the treatment, it must be limited to only the relationship of provider and patient. Medical providers are required to keep the identity of their patients’ secret. For confidentiality, a provider will not address you in public unless you initiate a conversation first. Your provider must decline any invitation to attend gatherings as well as must decline requests on all social networking sites. In sum, it is the duty of your provider to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way, but strictly for your long-term protection. Statement Regarding Ethics, Client Welfare and Safety U-First Healthcare assures that services rendered will be done in a consistent , professional manner in accordance with the governing bodies. If at any time you feel that your provider’s performance is unethical or unprofessional, we ask that you let the provider know immediately. If you are both unable to resolve the concern, please email us at info@ufirsthealthcare.org attention : Agency Director. Health Insurance Portability and Accountability Act (HIPAA) Rights. I acknowledge U-First Healthcare, LLC adheres to the federal mandates of the HIPAA laws. My signature bellow acknowledges receipt of this notice. I am able to receive the full disclosure in print, email or fax upon request. Your signature indicates that you have read and understood the contents of this form. You agree to the policies of your relationship with your provider and you are authorizing your clinician to begin treatment with you. You also agree to undergo mental health treatment and understand that you can end your treatment at any time. It should be discussed with your clinician, but you always reserve the right to stop treatment.DateLegal Guardian :DatePreviousNextFINANCIAL AGREEMENT U-First Healthcare, LLC seeks to keep medical costs down by ensuring we can get reimbursed for our services on a timely basis. To help our office provide the most efficient and reasonable health care services, it is necessary for us to have a financial policy indicating our requirements for payment of services provided to our clients. Structure and Cost of Sessions: Unless negotiated by your insurance carrier, your provider agrees to provide treatment and medication management at the following fee schedule: The fee for each visit will be due prior to the start of the session. The receipt of payment may also be used as a statement for insurance if applicable. Please note that insurances audit and will retract payment, making you fully liable, if they find the client ineligible at the time of services, i.e. your employer indicates a termination date, but services were paid to the provider after that date. Telephone Calls: Phone contact to set or rearrange appointment times or brief phone contact to obtain relevant treatment information will not be billed. Doing treatment by telephone is an option, however it requires advance scheduling and may not be covered by your insurance. If you need to talk to your practitioner between sessions as an emergency, you may be billed for that extra support. Telephone calls that exceed 10 minutes in duration will be billed at $1.00 per minute. If this is the case, you and your clinician will need to explore adding tele-mental sessions or develop other resources to help you in-between sessions. Ancillary Services: Time spent performing services that support your treatment, such as writing reports, paperwork, contact with outside parties by phone or letter, and supportive phone contact to the client outside of regular sessions, are not covered by insurance and will be billed directly to the client. Ancillary services such as these will be charged at $90.00 per need and due at the time of the request. Copy of records must be made in writing and emailed to info@ufirsthealthcare.org ATTN: Records Request and will be charged a fee of $25.88 plus $0.97 per page. Cancellation Policy & Fees: In the event, you are unable to keep an appointment, notify the office at least 24-hours in advance. If a notice is not received, you will be financially responsible for the visit you’ve missed. Insurance companies DO NOT reimburse for missed visits. To avoid a missed appt fee, a same-week reschedule can be made, if availability exists. Same day appointment cancellations at $45.00 per occurrence. Cancellations in the pre-hour of scheduled appointments and no-show appointments are charged at $60.00 per occurrence. Payment arrangements are mandatory prior to get back on the schedule. Legal/Court Policy & Fees: You are financially responsible for any fees related to legal/court matters. For instances requiring court attendance, U-First Healthcare, LLC will be paid a retainer at $300.00 per hour at a 3-hour minimum. Time spent dealing with legal requests like subpoenas/court orders, notarized letters, phone conversations with lawyers will be charged at $100.00 per instance. Court-related fees cover your clinician’s time, we do provide expert testimony. As a client with UFHC, legal fees that are incurred (regardless of who is making the request) the patient/patient guardian must make payment at least 14 days in advance prior to court attendance or on the day the subpoena has been received. By signing below, I AGREE to ALL terms and conditions of this financial agreement.Print Client Name :DateI, , hereby consent to authorization and treatment voluntarily at UFirst Healthcare, as agreed upon in the best interest of my health. I consent to the release and disclosure of my medical history, condition, and documentation that is necessary to process insurance claims, assist other medical professionals in continuation of care, or to another healthcare facility if admission is required. I understand that a copy of this signed release is valid as the original. I understand that I or the provider can discontinue this authorization at any time, in writing. I have read and understand this agreement and attest to all the information being provided, is true and accurate. I fully accept all terms of this agreement and will receive a copy, if requested. For Disclosure of Mental Health Treatment InformationI,WHOSE DATE OF BIRTH ISAUTHORIZE U-First Healthcare TO DISCLOSE TO AND TO OBTAIN ALL MEDICAL INFORMATION FROM : THIS INFORMATION MAY BE USED OR DISCLOSED IN CONNECTION WITH MENTAL HEALTH TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS. I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION, IN WRITING, AT ANY TIME, BY SENDING WRITTEN NOTIFICATION TO MY PROVIDER’S OFFICE. I FURTHER UNDERSTAND THAT A REVOCATION OF THE AUTHORIZATION IS NOT EFFECTIVE TO THE EXTENT THAT ACTION HAS BEEN TAKEN IN RELIANCE ON THE AUTHORIZATION. UNLESS YOU HAVE SPECIFICALLY REQUESTED IN WRITING THAT THE DISCLOSURE BE MADE IN A CERTAIN FORMAT, WE RESERVE THE RIGHT TO DISCLOSE INFORMATION, AS PERMITTED, BY THIS AUTHORIZATION, IN A MANNER WHICH WE DEEM APPROPRIATE AND CONSISTENT WITH APPLICABLE LAW, INCLUDING BUT NOT LIMITED TO, VERBAL, IN PAPER FORMAT, OR ELECTRONICALLY. I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be re-disclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations unless state law applies that is stricter than HIPAA and provides additional privacy protection. I will be given a copy of this authorization for my records, if requested.Date:Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.) Check here if patient/client refuses to sign authorizationDate:PreviousNextNOTICE OF PRIVACY PRACTICES Right to Request Amendment of Medical Information You Believe Is Erroneous or Incomplete: If you examine your medical information and believe that some of the information is wrong or incomplete, you may ask us to amend your record. To ask us to amend your medical information, call and speak to a supervisor. Right to Get a List of Certain Disclosures of Your Medical Information: You have the right to request a list of many of the disclosures we make of your medical information. If you would like to receive such a list, call a Supervisor. We will provide the first list to you free, but we may charge you for any additional lists you request during the same year. We will tell you in advance what this list will cost. Right to Request Restrictions on how the Clinic Will Use or Disclose Your Medical Information for Treatment, Payment, or Health Care Operations: You have the right to request that the Clinic not make disclosures of your medical information to treat you, to seek payment for care, or to operate the Clinic. In many cases, the Clinic is not required to agree to your request for restriction, but if we do agree, we will comply with that agreement. If you want to request a restriction, write to the Supervisor and describe your request in detail. However, the Clinic must agree to your request not to disclose to your health plan any medical information about items or services for which you have paid in full, unless such disclosure is required for treatment or by law. If you do not want the Clinic to disclose medical information to your health plan, you must notify us at the time of your registration as well as make immediate arrangements to pay in full for your treatment. Right to Request Confidential Communications: You have the right to ask us to communicate with you in a way that you feel is more confidential. For example, you can ask us not to call your home, but to communicate only by mail. To do this, write to the Supervisor. Upon request, you can also ask to speak with your health care providers in private outside the presence of other patients or family. Duties of the Clinic: The Clinic is required by law to protect the privacy of your medical information, give you this Notice of Privacy Practices, and follow the terms of the Notice that is currently in effect. The Clinic is also required to notify you if there is a breach of your unsecured medical information. Which Health Care Providers are Covered: This Notice of Privacy Practices applies to the Clinic and its personnel, volunteers, students and trainees. This Notice also applies to other health care providers when they come to the Clinic to care for patients, such as physicians, physician assistants, therapists, other health care providers who are not employed by the Clinic. However, these other health care providers may follow different practices at their own offices or facilities. Changes to this notice: From time to time, we may change our practices concerning how we use or disclose patient medical information, or how we will implement patient rights concerning their information. We reserve the right to change this Notice and to make the provisions in our new Notice effective for all medical information we maintain. If we change these practices, we will publish a revised Notice of Privacy Practices. You can get a copy of our current Notice of Privacy Practices at any time by contacting the Clinic. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are committed to protecting the confidentiality of your medical information, and are required by law to do so. This notice describes how we may use your medical information within the Clinic and how we may disclose it to others outside the Clinic. This notice also describes the rights you have concerning your own medical information. Please review it carefully and let us know if you have questions. How will we use and disclose your medical information? Treatment: We may use your medical information to provide you with medical services and supplies. We may also disclose your medical information to others who need that information to treat you, such as doctors, physician assistants, nurses, medical and nursing students, technicians, therapists, emergency service and medical transportation providers, and others involved in your care. For example, we will allow your primary care physician to have access to your Clinic medical record. To assure that your other treatment providers have quick access to your latest health information, we may participate in a community-based electronic health information exchange. We also may use and disclose your medical information to contact you to remind you of an upcoming appointment, to inform you about possible treatment options or alternatives, or to tell you about health-related services available to you, or to perform follow-up calls to monitor your care experience. Family Members, Legal Counsel, and Others Involved in Your Care: We may disclose your medical information to a family member, legal counsel, or friend who is involved in your medical care, or to someone who helps to pay for your care. Payment: We may use and disclose your medical information to get paid for the medical services and supplies we provide to you. For example, your health plan, Health Insurance Company, or attorney may ask to see parts of your medical record before they will pay us for your treatment. Clinic Operations: We may use and disclose your medical information if it is necessary to improve the quality of care we provide to patients or to run the Clinic. We may use your medical information to conduct quality improvement activities, to obtain audit, accounting or legal services, or to conduct business management and planning. For example, we may look at your medical record to evaluate the care provided by clinic personnel, your doctors, or other health care professionals. Required by Law: Federal, state, and local laws sometimes require us to disclose patients’ medical information. For instance, we are required to report child abuse or neglect and must provide certain information to law enforcement officials in domestic violence cases. We also are required to give information to the State Workers’ Compensation Program for work-related injuries. Public Health: We also may report certain medical information for public health purposes. For instance, we are required to report births, deaths, and communicable diseases to the State. We also may need to report patient problems with medications or medical products to the FDA, or may notify patients of recalls of products they are using. Public Safety: We may disclose medical information for public safety purposes in limited circumstances. We may disclose medical information to law enforcement officials in response to a search warrant or a grand jury subpoena. We also may disclose medical information to assist law enforcement officials in identifying or locating a person, to prosecute a crime of violence, to report deaths that may have resulted from criminal conduct at the Clinic. We also may disclose your medical information to law enforcement officials and others to prevent a serious threat to health or safety. Military, Veterans, National Security and Other Government Purposes: If you are a member of the armed forces, we may release your medical information as required by military command authorities or to the Department of Veterans Affairs. The Clinic may also disclose medical information to federal officials for intelligence and national security purposes, or for presidential Protective Services. Judicial Proceedings: The Clinic may disclose medical information if the Clinic is ordered to do so by a court or if the Clinic receives a subpoena or a search warrant. You will receive advance notice about this disclosure in most situations so that you will have a chance to object to sharing your medical information. Information with Additional Protection: Certain types of medical information have additional protection under state or federal law. For instance, medical information about communicable disease and HIV/AIDS, and evaluation and treatment for a serious mental illness is treated differently than other types of medical information. For those types of information, the Clinic is required to get your permission before disclosing that information to others in many circumstances. When is Your Authorization Required? Uses and Disclosures for Which Your Authorization is Required: With limited exceptions, the Clinic must obtain your written authorization before it may disclose your medical information in the following circumstances: (1) to disclose psychotherapy notes, (2) to conduct marketing activities, or (3) to sell your medical information to a third party. Other Uses and Disclosures Requiring Authorization: If the Clinic wishes to use or disclose your medical information for a purpose that is not discussed in this Notice, the Clinic will seek your written authorization. If you give your authorization to the Clinic, you may take back that authorization any time, unless we have already relied on your authorization to use or disclose the information. If you ever would like to revoke your authorization, please notify the Supervisor in writing.PreviousNextINFORMED CONSENT FOR MEDICATIONPatient Name:Birthdate:Guardian Name:Relationship:Name of Pharmacy :Pharmacy Address:Pharmacy Number: U-First Healthcare offers family medical, psychiatric, medical detoxification, weight management, and psychotherapy treatments. When meeting with the psychiatric providers the appointment will include the assessment of your mental health condition and treatment options. During the visit, you and your provider will discuss: The nature of your mental condition. Your physician’s reasons for prescribing the medication, including the likelihood of your condition improving or not improving without the medicine. The importance of medication compliance and the option to discuss with your prescribing physician any desire to stop taking any medication. Reasonable alternative treatments that are available for your condition. There may be a need for initial or periodic medical or laboratory consultations with the use of these medication(s). That certain antipsychotic medications may cause additional side effects for some persons, including tardive dyskinesia. Tardive dyskinesia is defined as persistent involuntary movements of the face, mouth, torso, hands, or feet. These symptoms are potentially irreversible, and may continue after the antipsychotic medication has been stopped. I was given information about the recommended medication. I understand that the information does not cover everything, but it includes items of clinical significance to me. I should discuss all my medical problems and any medication that I take with my healthcare provider or physician(s). For more information, I may refer to a pharmacist or to a standard text such as the Physician’s Desk Reference (PDR). U-First Healthcare: 1479 Brockett Road Suite 101 Tucker, GA 30084 Office: 1-833-645-4653 Fax: 1-866-892-3005 www.U-First Healthcare.orgDate:MEDICAL / PSYCHIATRY FOLLOW UP VISITS :Prescribing providers provide prescriptions for medications during appointments. They will rarelyapprove refill requests from patients or pharmacies outside of an appointment.This practice: • reduces prescription errors• improves patient safety and• encourages appropriate follow-up. It also improves compliance with state laws governing controlled substances. Patients receive enough medication or refills to last until their next recommended follow-up. It istherefore important to make and comply with follow-up appointments. Please be proactive in your care and track how much medication you have and how many refills remainon your prescription., and ensure you have an appointment to see the doctor before you run out ofmedication. In instances of emergencies, a fee applies when a patient needs a between-visits refill. • I understand that I may refuse medication(s) unless the refusal would be unsafe to me/my child orothers.• Many psychiatric medications can cause sensitivity to sunlight or decrease the body’s ability to handlethe heat when being used. Using sunscreen when outdoors and drinking fluids when sweating or in hotsettings is good practice on or off medications.• If there are questions about other potential side effects, I know I can contact the prescribing physician. •I understand the potential benefits, side effects, and alternatives, and I agree to the medication treatmentrecommended.Please print, date, and sign your name below indicating that you have read and understood the contentsof this form, you agree to the policies of your relationship with your provider, and you are authorizingyour clinician to begin treatment with you. By signing this you also agree to undergo mental healthtreatment and understand that you can end treatment at any time. It should be discussed with yourphysician, but you always reserve the right to stop treatment.Patient Name (Please Print) Date:If Applicable: Legal Guardian’s Name (Please Print) Date:PreviousNext CREDIT CARD “ON FILE ” AUTHORIZATION FORMU-First Healthcare, LLC is authorized to maintain credit card payment information in my confidential file. This permits U-First Healthcare, LLC to charge for upcoming treatment sessions and missed appointments. Your signature authorizes UFHC to review this information and deduct fees from the credit card below. Should the credit card decline, an additional fee to the outstanding balance of $15.00. It is the patient’s responsibility to provide Renewed Journey with new payment information within 24 hours of card declination for the full amount due to avoid future appointments being canceled.Date of Authorization:Patient Name:Date:Cardholder Name (as written on credit card):Credit Card Billing Address: ): Card Number:Card Expiration:Card type: VISA HSA Master Card American Express Discover*Most HSAs prohibit missed appointment fees to be accepted. If audited, you will be expected to reimburse your HSA plan directly. Permission granted to maintain my credit card information on file and automatically charge my credit card when payments are due. I agree that I will pay for this purchase in accordance with the issuing bank card holder agreement.Date:PreviousNextCONSENT & AUTHORIZATION TO RELEASE INFORMATIONIf there are other parties that may assist in your therapy, and you believe it would be helpful for your therapist to contact them regarding your treatment, please read carefully and complete this document.The following is an authorization for the stated parties to consult with one another regarding your treatment process. Information shared is for the sole purpose of facilitating maximum care to you as the client. Please provide thenecessary information and your signature with today’s date as indicated below.*******************************************************************************************I,(client), hereby authorize U-First Healthcare and the following party or parties to discuss my mental health treatment information and records obtained in the course of psychotherapy treatment, including, but not limited to, therapist’s diagnosis:(1)(2)(3)Please note that treatment is not conditioned upon your signing this authorization, and you have the right to refuse to sign this form. Please indicate your preference regarding the information to be shared:The parties stated above may discuss my medical and/or mental health information without limitationsI would prefer to limit the information shared between the parties stated above. The limitations I would like to make are as follows:Additionally, the above-named parties, therapist & person(s) or entity (entities) designated under (1) or (2), agree to exchange information only between themselves (or their agents). Any disclosure of information extended beyond these< parties is considered a breach of confidentiality. Your signature below indicates that you understand that you have a right to receive a copy of this authorization. Your signature also indicates that you are aware that any cancellation or modification of this authorization must be in writing, and you have the right to revoke this authorization at any time unless the therapist stated above has taken action in reliance upon it. Additionally, if you decide to revoke this authorization, such revocation must be in writing and received by U-First Healthcare at 1479 Brockett Road Suite 101 Tucker, GA 30084 to go into effect.Date:Date:PreviousNextPatient Health Questionnaire (PHQ-9)Important Notice: The information gathered on this questionnaire will remain confidential.PHQ-9Over the last two weeks, how often have you been bothered by the following problems?1. Little interest or pleasure in doing things. Not at all Several days More than half the days Nearly every day2. Feeling down, depressed or hopeless Not at all Several days More than half the days Nearly every day3. Trouble falling asleep or staying asleep or sleeping too much Not at all Several days More than half the days Nearly every day4. Feeling tired or having little energy Not at all Several days More than half the days Nearly every day5. Poor appetite or overeating. Not at all Several days More than half the days Nearly every day6. Feeling bad about yourself, that you are a failure, you have let yourself or your family down. Not at all Several days More than half the days Nearly every day7. Trouble concentrating on things, such as reading the newspaper or watching the TV. Not at all Several days More than half the days Nearly every day8. 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. Not at all Several days More than half the days Nearly every day9. Thoughts that you would be better off dead or hurting yourself in some way Not at all Several days More than half the days Nearly every dayIf 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 Add the score for each columnTotal of 1'sTotal of 2'sTotal of 3'sTotal Score (add you column scores)Generalized Anxiety Disorder 7-item (GAD-7)Over the last 2 weeks how often have you been bothered by the following problems?1. Feeling nervous. anxious, on on edge Not all all sure-0 Several days - 1 Over half the days-2 Nearly everyday-32. Not being able to stop or control worrying Not all all sure-0 Several days - 1 Over half the days-2 Nearly everyday-33. Worrying too much about different things Not all all sure-0 Several days - 1 Over half the days-2 Nearly everyday-34. Trouble relaxing Not all all sure-0 Several days - 1 Over half the days-2 Nearly everyday-35. Being so restless that it's hard to sit still Not all all sure-0 Several days - 1 Over half the days-2 Nearly everyday-36. Becoming easily annoyed or irritable Not all all sure-0 Several days - 1 Over half the days-2 Nearly everyday-37. Feeling afraid as if something awful might happen Not all all sure-0 Several days - 1 Over half the days-2 Nearly everyday-3 Add the score for each columnTotal of 1'sTotal of 2'sTotal of 3'sTotal Score (add you column scores)PreviousNextCOLUMBIA-SUICIDE SEVERITY RATING SCALE Screen VersionSUICIDE IDEATION DEFINITIONS AND PROMPTS Ask questions that are bolded and underlined. Yes/No Ask Questions 1 and 2 1) Wish to be Dead: Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.Have you wished you were dead or wished you could go to sleep and not wake up? Yes No2) Suicidal Thoughts: General non-specific thoughts of wanting to end one’s life/commit suicide, “I’ve thought about killing myself” without general thoughts of ways to kill oneself/associated methods, intent, or plan.Have you actually had any thoughts of killing yourself? Yes NoIf YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6 3) Suicidal Thoughts with Method (without Specific Plan or Intent to Act): Person endorses thoughts of suicide and has thought of a least one method during the assessment period. This is different than a specific plan with time, place or method details worked out. “I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it….and I would never go through with it.”Have you been thinking about how you might kill yourself? Yes No4) Suicidal Intent (without Specific Plan):Active suicidal thoughts of killing oneself and patient reports having some intent to act on such thoughts, as opposed to “I have the thoughts but I definitely will not do anything about them.”Have you had these thoughts and had some intention of acting on them? Yes No 5) Suicide Intent with Specific Plan:Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out.Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Yes No 6) Suicide Behavior Question:Have you ever done anything, started to do anything, or prepared to do anything to end your life? Yes No Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etcIf YES, ask: How long ago did you do any of these? Over a year ago? Between three months and a year ago? Within the last three months?PreviousNextADHD Assessment for ChildrenDate:Sex :Age :Grade :Completed by Mother Father Guardian Grandparent1. Fails to give close attention to details or make careless mistakes in schoolwork Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 32. Fidget with hands or feet or squirm in seat Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 33. Has difficulty sustaining attention in tasks or fun activities Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 34. Leaves seat in classroom or in other situations in which remaining seated is expected Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 35. Does not listen when spoken to directly Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 36. Runs not seem to listen when spoken to directly Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 37. Don’t follow through on instructions and fail to finish work Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 38. Has difficulty playing or engaging in leisure activities Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 39. Has difficulty organizing tasks and activities Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 310. Is “on the go” or acts as if “driven by a motor” Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 311. Avoids tasks (e.g., school work, homework) that require sustained mental effort Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 312. Talk excessively Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 313. Loses things necessary for tasks or activities Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 314. Blurt out answers before questions have been completed Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 315. Is easily distracted Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 316. Has difficulty awaiting turn Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 317. Is forgetful in daily activities Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 318. Interrupts or intrudes on others Never or Rarely - 0 Sometimes - 1 Often - 2 Very Often - 3Date: Previous Submit Form