New Patient Paper Work Forms

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New Patient Paperwork

Greater Heights Holistic Psychiatry

Please complete the following information before your appointment.

1. Patient Information

First Name *

Last Name *

Date of Birth *

Mobile Phone *

Email Address *

Street Address *

City

State

ZIP Code

2. Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Phone

3. Insurance Information

Please provide your current insurance information. Insurance benefits are verified as a courtesy and verification does not guarantee payment by your insurance company.

Patients are responsible for applicable deductibles, copayments, coinsurance, non-covered services, and balances not paid by the insurance company.

Insurance Company *

Member ID

Group Number

Plan Name

4. Reason for Visit

What brings you to Greater Heights Holistic Psychiatry? *

What would you like to accomplish through treatment?

5. Psychiatric History

Have you previously received psychiatric or mental health treatment?

Please provide any relevant previous psychiatric treatment, diagnoses, therapy, or hospitalization history.

6. ADHD Evaluation & Treatment

If you are seeking an ADHD evaluation or treatment, please provide relevant information about previous evaluations, diagnoses, treatment, testing, or medications.

Are you seeking evaluation or treatment for ADHD?

Additional ADHD Information

7. Current & Previous Medications

Please list all prescription medications, over-the-counter medications, vitamins, supplements, and other medications you are currently taking or have previously taken.

For medications you are currently taking, leave the End Date blank and select Yes under Current?.

I am not currently taking any medications.

Medication Name *	Dosage	Frequency	Route	Reason / Diagnosis	Prescriber	Start Date	End Date	Current?

Medication Allergies / Adverse Reactions

8. Pharmacy Information

Pharmacy Name

Pharmacy Phone

Pharmacy Address

Medication refill requests and prior authorization requests may require additional information and processing time.

9. Medical History

Please list any significant medical conditions, surgeries, or other relevant medical history.

Primary Care Provider

10. Financial Policy Acknowledgment

Patient Financial Responsibility

Insurance verification is performed as a courtesy. Patients remain responsible for deductibles, copayments, coinsurance, non-covered services, and any balance not paid by the insurance company.

I understand and agree that I am responsible for applicable patient financial responsibilities. *

11. No-Show & Late Cancellation Policy

A minimum of 48 business hours notice is required to cancel or reschedule an appointment.

New Patient Appointment: $200 late cancellation / no-show fee.
Follow-Up Appointment: $100 late cancellation / no-show fee.

Please refer to the complete practice financial policy for additional details.

I have read and understand the No-Show and Late Cancellation Policy. *

12. Privacy & HIPAA Acknowledgment

Greater Heights Holistic Psychiatry maintains patient privacy in accordance with applicable federal and state privacy requirements.

Patients may request a copy of the practice's Notice of Privacy Practices.

I acknowledge that I have been provided information regarding the Notice of Privacy Practices. *

13. Consent & Patient Acknowledgment

I consent to psychiatric evaluation and treatment and understand that treatment recommendations will be discussed with me by my healthcare provider. *

I certify that the information I have provided is accurate and complete to the best of my knowledge. *

14. Patient Signature

Patient / Legal Representative Name *

Date *

Electronic Signature *

I understand that typing my name above constitutes my electronic signature and acknowledgment of the information and policies presented in this form. *

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