Forms

Prior to scheduling an appointment, please complete the intake form so we can verify benefits and get you registered in our system. Be sure to also complete the consent and HIPAA forms and submit them in advance of your appointment.

You can complete the Consent and HIPPA Forms either as a pdf or print and send them by email.

Intake Form

Referred by
Date
Date Format: MM slash DD slash YYYY
Patient Name
First Last
Age
Date of Birth
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Adress
Home Phone
Work
Cell
Insurance Carrier and Phone #
Policy ID #
Name of Insured
Authorization # (if needed)
Occupation
Spouse's Occupation
Place of Employment/School
Marital Status
Spouse's Name
Who else is living in home
If child, Mother's name
age
Occupation
Father's name
age
Occupation
Parents are:
- Married
- Living Together
- Separated
- Divorced
Previous mental health treatment for self or family members (please specify)
Is there a family history of psychiatric hospitalizations? Suicides? Bipolar Disorder? (Please specify who and when)
Primary Care Physician
Last Visit
Psychiatrist, if applicable
Last Visit
Please list health problems & results of most recent lab tests
Current Medications
Past Medications
Good Responses
Bad Responses
Chief Complaint or Symptoms
What are your expectations from this consultation?
Describe your past and current use of drugs and/or alcohol
Have you ever seriously considered or attempted suicide? When?
Have you ever ben admitted to a psychiatric hospital? If so, please describe
Do you have current legal difficulties? If so, please describe
Please provide any additional information you think would be helpful

Additional forms:

Sleep Health Screener (SDSCL-25)

This is a 25-item scale that helps to identify signs or symptoms of 13 sleep disorders. It takes just 3-5 minutes to complete. Copy and paste this link into your browser so you can complete it online: sleephealthscreen.com

After you complete it you’ll get a downloadable pdf of the results. Please attach the pdf and email the results to me.

Consensus Sleep Diary (CSD-M)

This is a sleep diary you’ll use to keep track of sleep.

Copy and paste this link into your browser so you can download the form:

https://www.sleep.pitt.edu/wp-content/uploads/Study_Instruments_Measures/Consensus-Sleep-Diary-Morning-and-instructions.pdf