New Patient Paperwork- Georgia Psychiatry and Sleep

Complete this form to make a new patient appointment.

Call us at (770)438-1799 ext 2 with any questions
Hightop Health- SmyrnaHightop Health- Douglasville

Patient's Full Name*

First NameMiddle NameLast Name
Preferred Name

NoYes

Pictures of the front and back of your insurance card and driver's license are required PRIOR to scheduling an appointment.
Insurance Company *
Insurance Member ID Number*
Subscribers information

First NameLast Name
Subscribers Date of Birth

MonthDayYear
Date
Attach a picture of the FRONT of your insurance card.

Cancelof
Attach a picture of the BACK of your insurance card.

Cancelof
Attach a picture of the FRONT of your Driver's License/Government-Issued ID.

Cancelof

Rows	I Acknowledge
There is a new patient no-show fee of $400. This will be required to be paid before our staff are able to reschedule an initial appointment. The credit card on file will be charged automatically.
We require at least 48-hour notice (business days) for any new patient appointment cancellations. Failure to do so will result in a cancellation fee of $100 that will be required to be paid before the appointment can be rescheduled. The credit card on file will be charged automatically.
There is an existing patient same-day cancellation fee of $200 for medication management. There is a $200 no show fee for existing patient medication management appointments. The credit card on file will be charged automatically.
A urine drug screening is required for ALL medication management new patients and can be requested at any time at a follow-up visit at the discretion of your provider. The cost of this screening is $25.
Patients with 3 or more missed/cancelled appointments may be considered for possible termination from our practice.
Patient responsibility is due at the time of service. The card on file will be charged the morning of your appointment.
A follow up appointment is required to obtain medication refills. If for any reason a medication refill is approved by our provider prior to a follow up appointment, a fee of $25 will be automatically charged to the card on file for any medication refills, dosing/medication change or pharmacy change. Allow up to 72 hours for a refill.
All insurance, address, phone number, and pharmacy changes need to be updated with our office.
Disability cases will NOT be completed at our office.
We require at least 48 hour notice (business days) for any talk therapy appointment cancellations. Failure to do so will result in a $175 cancellation fee. There is a therapy no-show fee of $175. The credit card on file will be charged automatically.

Please list ALL current medications. Make sure to list medication name, dosage, frequency, and route.*
Drug Name, Dose, Frequency, Route. Type N/A if you have no current medications
List any psychiatric medications you have tried in the past.*
Drug Name, Dose, Prescriber, Dates Used, Why did you stop? Type N/A if you have not tried any psychiatric medications in the past.
Are you allergic to any medications?*
Type N/A if not applicable.
Signature*

Clear
Today's Date *

MonthDayYear
Date

Rows	Parent/Guardian 1
Name
Date of Birth
Contact Number
Can give consent to treatment? Y/N

Rows	Parent/Guardian 2
Name
Date of Birth
Contact Number
Can give consent to treatment? Y/N

Rows	Name	Relationship	Phone Number
ROI Person #1
ROI Person #2

Insurance Company *
Insurance Member ID Number*
Attach a picture of the FRONT of your insurance card.

Cancelof
Attach a picture of the BACK of your insurance card.

Cancelof
Attach a picture of the FRONT of your Driver's License/Government-Issued ID.

Cancelof

Rows	I Acknowledge
There is a new patient no-show fee of $100. This will be required before our staff are able to reschedule an initial appointment. The credit card on file will be charged automatically.
We do require 48 hours (business day) notice for any new patient appointment cancellations. Failure to do so will result in a $100 fee that will be required before the initial appointment can be rescheduled. The credit card on file will be charged automatically.
There is an existing patient no-show fee of $50 for medication management. There is a existing patient same day cancellation fee of $50 for medication management. The credit card on file will be charged automatically.
We require at least 48 hours (business day) notice for any talk therapy appointment cancellations. Failure to do so will result in a $100 cancellation fee. There is a therapy no-show fee of $100. The credit card on file will be charged automatically.
A urine drug screening is required for ALL medication management new patients and can be requested at any time at a follow-up visit at the discretion of your provider. The cost of this screening is $15.
Patients with 3 or more missed/cancelled appointments may be considered for possible termination from our practice.
Patient responsibility is due at the time of service. The card on file will be charged the morning of your appointment.
Any medication refill requests will be considered on a case-to-case basis and must be approved by your provider. If approved without an appointment, there is a $25 refill fee. The credit card on file will be charged automatically.
All insurance, address, phone number, and pharmacy changes need to be updated with our office.
Any disability cases will NOT be filled out at an initial evaluation.
A parent or legal guardian is required to be present for a child's medication management appointment.

List ALL current medications your child/teen is taking. Make sure to list medication name, dosage, frequency, and date started.*
List medication name, dosage, prescriber, and date started. Type N/A if no current medications.
List any psychiatric medications your child/teen has tried in the past (not listed above)*
List medication name, dosage, provider dates taken, and reason for stopping. Type N/A if no past psychiatric medications.
YesNo
If yes, please list all drug allergies*
Type N/A if not applicable.

Parent/Legal Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Rows	Not at all (0)	Several Days (1)	More than half of the days (2)	Nearly every day (3)
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching TV
Moving or speaking so slowly that other people have noticed? Or the opposite- being so fidgety/restless that you have been moving around more than usual
Thoughts that you would be better off dead or hurting yourself in some way

Rows	Not at all (0)	Several Days (1)	More than half the days (2)	Nearly every day (3)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

Rows	Never	Rarely	Sometimes	Often	Very Often
How often do you have trouble wrapping up the final detail of a project, once the challenging parts have been done?
How often do you have difficulty getting things done when you have to do a task that requires organization?
How often do you have trouble remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid/delay getting started?
How often do you fidget or squirm with your hands/feet when you have to sit down for a long time?
How often do you feel overly active and compelled to do things, like you were driven by a motor?

Rows	Least Likely (0)	Somewhat likely (1)	Likely (2)	Most likely (3)
Sitting and relaxing
Watching TV
Sitting inactive in a public place (Ex: in a meeting or theater)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car while stopped for a few minutes in traffic

Rows	Yes	No
Has there ever been a period of time when you were not your usual self?
You felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
You were so irritable that you shouted at people or started arguments/fights?
You felt much more self confident than usual
You got much less sleep than usual and found that you didn't really miss it?
You were much more talkative or spoke much faster than usual?
Thoughts raced through your head or you couldn't slow your mind down?
You were so easily distracted by things around you that you had trouble concentrating or staying on track?
Had much more energy than usual?
You were much more active or did many more things than usual?
You were much more social or outgoing than usual?
You were much more interested in sex than usual?
You did things that were unusual for you or that other people thought were excessive, foolish, risky?
Spending money got you or your family in trouble?

Complete this form to make a new patient appointment.

Scales/Questionnaires

Social History

Rows	Yes	No
Have there been at least 6 different periods of time (at least 2 weeks) when you felt deeply depressed?
Did you have problems with depression before the age of 18?
Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?
Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?
Have you ever had a period of at least 1 week during which you felt any of the following: unusually happy, unusually outgoing, or unusually energetic?
Have you ever had a period of at least 1 week during which you needed less sleep than usual?

Rows	Yes	No
Do you work shifts?
Do you feel your work, home, social life is affected by your shifts?
Do you feel tired/sleepy when you need to be awake?
Do you snore loudly on most nights?
Do you have morning headaches?
Does anyone in your family snore loudly or have sleep apnea?
Have you, as a driver, been in a car accident because of sleepiness?
Have you ever sleepwalked as an adult?
Do you have creepy, crawly legs at nights that keep you awake most nights of the week?
Do you have "sleep attacks" during the day while laughing or experiencing strong emotions?

Rows	Yes	No
Generally healthy
Changes in weight or changes in strength/exercise tolerance
Headaches, vertigo, head injury
Changes in hearing, ringing in ears, bleeding in ears, vertigo
Nose bleeds, colds, congestion/discharge
Dental difficulties, gingival bleeding, use of dentures
Chest pain, palpitations, fainting, shortness of breath, irregular heartbeat
Change in appetite, abdominal pains, bowel habit changes
Urinary urgency, painful urination, change in nature of urine
Change in menses, cramping, pelvic pain
Pain in muscles/joints, limitation of range of motion, tingling or numbness
Weakness, tremors, seizures, change in mental function, problems with muscle coordination
Changes in sleep habits, difficulty sleeping, insomnia

Rows	Self	Mother	Father	Sibling
Bipolar disorder
Depression
Anxiety
Addiction
ADHD
Schizophrenia
Family history of completed suicide
Heart Disease/Structural heart defects
Sudden cardiac death (sudden heart attack in 20s/30s)
Heart arrhythmias
Seizures
High blood pressure
Thyroid disease
Kidney disease
Liver disease (Hepatitis/Cirrhosis)
Sleep Apnea
Narcolepsy
Autoimmune disease
Diabetes
Coronary Artery Disease
Congestive Heart Failure
Stroke
NONE OF THESE APPLY

Rows	Yes	No
No Legal Problems
Spent time in jail
On probation currently
Court-Ordered Treatment

Rows	Never	Occasionally (1)	Often (2)	Very Often (3)
Does not give close attention to details or makes careless mistakes in school/work
Has difficulty sustaining attention in tasks/play activities
Does not seem to listen when spoken to directly
Does not follow through on instructions and fails to finish school work/chores (not due to oppositional behavior or failure to understand directions)
Has difficulty organizing tasks and activities
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as school work/homework)
Loses things necessary for tasks/activities such as toys, books, assignments, etc.
Is often easily distracted
Is often forgetful in daily activities
Fidgets with hands or feet or squirms in seat
Leaves seat in classroom or in other situations in which remaining seated is expected
Runs about or climbs excessively in inappropriate situations
Has difficulty playing or engaging in leisure activities quietly
Often "on the go" or often acts as if driven by a motor
Talks excessively
Blurts out answers before questions are completed
Has difficulty waiting their turn
Interrupts/intrudes on others

Rows	Yes	No
Felt so good or hyper that you thought they were not their normal self or they were so hyper that it got them into trouble?
Was so irritable that they shouted at people or started fights/arguments?
Seemed to feel more self-confident than usual?
Got much less sleep than usual and seemed like they didn't really miss it?
Was so much more talkative or spoke much faster than usual?
Seemed as though their thoughts were racing or they couldn't slow their mind down?
Was so easily distracted by things around them that they had trouble concentrating or staying on track?
Had much more energy than usual?
Was much more active or did many more things than usual?
Was much more social or outgoing than usual?
Did things that were unusual for them or that other people might've thought were excessive, foolish, or risky?

Rows	Yes	No
Do you feel like your child's school/home/social life is negatively affected by their sleep habits?
Does your child feel tired or sleepy when they need to be awake?
Does your child snore loudly on most nights?
Does your child have morning headaches?
Does anyone in your family snore loudly or have sleep apnea?
Does your child sleep walk?
Does your child have creepy, crawly legs at night that keep them awake most nights of the week?
Does your child have "sleep attacks" during the day while laughing or experiencing strong emotions?

Rows	Yes	No
Abnormal changes in weight or changes in strength/exercise tolerance
Frequent headaches, head injury
Changes in hearing, ringing in ears, bleeding in ears, vertigo
Frequent nose bleeds, colds, congestion, discharge
Dental difficulties, gingival bleeding, use of dentures
Difficultly breathing, wheezing, coughing blood, cough
Chest pains, palpitations, fainting, shortness of breath, irregular heartbeat
Urinary urgency, painful urination, changes in nature of urine
Change in menses, cramping, pelvic pain
Pain in muscles/joints, limitation of range of motion, tingling, numbness
Weakness, tremors, seizures, changes in mental function, problems with muscle coordination
Changes in sleep habits, difficulty sleeping, insomnia

Rows	Yes	No
Alcohol
Marijuana
Opiates
Cocaine
Meth
Kratom

Rows	Yes	No
Alcohol
Marijuana
Opiates
Cocaine
Meth
Kratom