LOWCOUNTRY PSYCHIATRIC ASSOCIATES
NEW PATIENT HISTORY:
Name:_________________________________
Date___________________________________
In a few words, what are the problem(s) you are seeking help for today?
__________________________________________________________________________________________
Current Symptoms/Problem Checklist: Please check any symptoms….
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) Depression
) Unable to enjoy activities
) Sleep disturbance
) Loss of interest
) Concentration/Memory
) Change in appetite
) Increased irritability
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) Racing thoughts
) Impulsivity
) Increase risky behavior
) Increased/decreased libido
) Decrease need for sleep
) Excessive energy
) Fatigue
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) Excessive worry
) Anxiety/Panic
) Avoidance
) Hallucinations
) Suspiciousness
) Excessive guilt
) Crying spells
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) Substance Abuse
) Family Issues
) Legal Issues
) Loss/Bereavement
) Pain Issues
OTHER:___________________________________________________________________________________
Suicide Risk
Have you ever tried to harm yourself in the past? ( ) Yes ( ) No.
Have you had any recent thoughts, or do you currently have any thoughts of suicide? ( ) Yes ( ) No.
Medical History:
Allergies___________________________________________ Current Weight ____________ Height _______
List ALL current medications and how often you take them/dosage:
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Current over-the-counter medications or supplements:___________________________________________
Current/Past major medical problems (chronic illness, surgeries, hospitalizations…)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
For women:
Date of last menstrual period: _______Are you currently, or do you think you are pregnant?( )Yes( ) No.
Are you planning to get pregnant in the near future? ( ) Yes ( ) No
Family History (Medical/Psychiatric Diagnoses, Substance Abuse or Self-Injury/Suicide):
____________________________________________________________________________________
____________________________________________________________________________________
Past Psychiatric History
Outpatient treatment ( ) Yes ( ) No. If yes, Please describe when, by whom, and nature of treatment.
____________________________________________________________________________________
____________________________________________________________________________________
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Psychiatric Hospitalization ( ) Yes ( ) No If yes, describe for what reason, when and where.
____________________________________________________________________________________
Past Psychiatric Medications: If you have ever taken any of the following medications (please circle).
Mood/Thoughts: Prozac, Zoloft, Luvox, Paxil, Celexa, Lexapro, Viibryd, Effexor, Cymbalta,Wellbutrin, Remeron, Serzone, Anafranil,
Pamelor,Tofranil, Elavil, Tegretol, Lithium, Lamictal, Tegretol, Topamax, Seroquel, Zyprexa, Geodon, Abilify, Clozaril, Haldol,
Prolixin
Sleep: Ambien, Lunesta, Sonata, Rozerem, Restoril, Desyrel/trazodone
ADHD: Adderall, Concerta, Ritalin, Vyvanse, Focalin, Dexedrine, Strattera
Anxiety: Xanax, Ativan, Klonopin, Valium, Restoril, Librium,Tranxene, Buspar, Vistaril, Benadryl, Propranolol
Other: ______________________________________________________________________________
Any negative/positive experiences with these medications? ____________________________________
____________________________________________________________________________________
Substance Use:
Do you (or others) think you may have a problem with alcohol or drug use? ( ) Yes ( ) No
Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No
If yes, for which substances and when/where were you treated? ________________________________
Days/wk drinking alcohol: _____ Avg. Number drinks/day: _________ Most drinks/day: ___________
Do you have current/past problems with the use/abuse of illegal substances? If so, which substances?
____________________________________________________________________________________
Have you abused prescription medication? If so, which medications? ____________________________
How many caffeinated beverages do you drink a day? Coffee _____ Sodas ________ Tea ___________
Tobacco History: active__________________________ past________________________________
Family Background and Childhood History:
Where were you born___________________________ where did you grow up ________________________
Were you adopted? ( ) Yes ( ) No
Did your parents’ divorce? ( ) Yes ( ) No Your age at their divorce:_______ you lived with___________________
List your siblings and their ages: Sisters (ages)______________________________________________________
Brothers (ages)________________________________________________________________________________
Educational History:
What is your highest educational level or degree attained? _____________________________________
Spiritual life: Do you belong to a particular religion or spiritual group? __________________________
Trauma History:
Do you have a history of being abused emotionally, sexually, physically or by neglect? ( ) Yes ( ) No.
Occupational History:
Are you currently: ( ) Working ( ) Not working by choice ( ) Unemployed ( ) Disabled ( ) Retired
What is/was your occupation? __________________________________________________________________
Have you ever served in the military? _______ If so, what branch and when? _____________________________
Relationship History and Current Family:
Are you currently: ( ) Married ( ) Divorced ( ) Single ( ) Widowed
How long? _____ Total number of marriages?______
If not married, are you currently in a relationship? ( ) Yes ( ) No If yes, how long? _________________________
Do you have children? ( ) Yes ( ) No. If yes, list ages and gender_______________________________________
Legal: Have you ever been arrested? _______ Do you have any pending legal problems?___________________
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******OFFICE POLICIES******
PHONE CALLS/AFTER HOURS CALLS/TELEPHONE CONSULTATIONS: We typically return routine/non-urgent phone calls within the
same business day if the message is left within normal business hours. Our policy is to provide quality patient care through scheduled office visits, not
unscheduled phone calls, and we may direct you to make an appointment. If it is an urgent matter, you may dial our after-hours number (866.256.4501)
to contact a provider. After hours phone calls in excess of five minutes will be charged a rate consistent with office time, and are not covered by
insurance.
EMERGENCIES:
In the event of any emergency, please go to the nearest emergency room or call 911 immediately. You may also contact your provider through the
after-hours line, after taking the step above.
MEDICATION REFILLS:
Please recognize when you are short on medication and call your pharmacy. Often patients have refills on file. If not, ask the pharmacy to fax the
office a medication refill request for your doctor to review. It is best to notify your pharmacy at least 5 business days before you would run out of
medication. If you call the office needing refill of medication within 48 hours, you will be charged $25.
MISSED/LATE APPOINTMENTS:
Missed appointments not canceled within 24 hours’ notice will be charged. Charges for missed appointments are usually not covered by insurance.
MEDICAL FORMS/PATIENT REQUESTED LETTERS:
Charges to complete medical forms and patient requested letters are usually not covered by insurance companies and are the responsibility of the
patient. Fees may vary according to the length and complexity of the form or requested letter. Payment is due prior to picking up or mailing the
requested document.
PAYMENT
Walters,MD/Ford, MD If am being treated by Joseph Walters, MD or Richard Ford, MD:
* I understand, they are NON-PARTICIPATING in my insurance plan, including MEDICARE/MEDICAID.
* I agree to accept full responsibility for payment of fees incurred at the time of each visit.
* I will be made available necessary billing/procedure codes for the type of treatment I receive from Dr. Walters/Ford, which can be submitted to my
insurance carrier for any reimbursement for which I may be eligible.
Scott, LPC/Veilleux, Ph.D. If I am being treated by Catherine Scott, LPC or by Suzanne Veilleux, Ph.D.:
*If I am 'self-pay', payment will be due at the time service is rendered.
*If I have insurance, I acknowledge that LPA may disclose protected health information to my insurance carrier or other third party responsible for my
bill as required in order to receive reimbursement for services provided.
* Medical Insurance: We strongly urge you to thoroughly review your insurance plan prior to your appointment. The type of plan chosen by you
determines your insurance benefits. We will electronically (or paper) file your medical insurance claims and bill your medical insurance for treatment
you receive. However, in the event the insurance company does not pay the bill, the balance will become the patient’s responsibility.
*I authorize and request assignment of benefits to be paid directly to LPA. I acknowledge and agree to pay any unpaid balances not covered by my
insurance policy, including deductibles, co-payments, and unauthorized or out of network services. Copayments and deductibles are to be paid at each
appointment.
*Our staff is happy to help with insurance questions related to how a claim was filed, or regarding information the carrier may need to process a claim.
Specific coverage issues, however, can only be addressed by your insurance company. Please contact Customer Service at the number listed on your
insurance card.
PROFESSIONAL FEE SCHEDULE: (fees are self-pay, otherwise according to your insurance policy)
Psychiatry (FORD/WALTERS,MD)
Counseling-Therapy (Dr. Scott)
Psychotherapy (Dr. Veilleux)
60 min intake evaluation = $250
45 min intake = $150
60 min intake = $200
45 min: therapy +/- meds) = $175
45 min follow up = $120
60 min follow up = $200
20-25 min: therapy +/- meds) = $120
45 min follow up = $150
10-15 min: therapy +/- meds) = $90
30 min follow up = $100
All Providers:
Phone calls/Consultations = The first 5 minutes are free. Thereafter it is $40 every 10 minutes (not covered by insurance)
Report writing = $100 for 30 minutes, $150 for 45 minutes, $200 for 60 minutes
NOTE: Phone calls/Consultations and Report Writing are (generally) not covered by insurance companies.
DELINQUENT FEES:
Fees are expected to be paid at the time of service, unless prior arrangements have been made through the front office.
PRINT NAME: _____________________________
SIGNATURE: ______________________________
DATE: ___________________________________
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