Patient Form Downloadable Form Patient Rights and Responsibilities PHQ 9 Age 11 to 17 PHQ 9 Questionaire Generalized Anxiety Disorder 7-item (GAD-7) scale Screen for Child Anxiety Related Disorders (SCARED) Vanderbilt ADHD Diagnostic Teacher Rating Scale Prompt Solutions Privacy Policy Adult Adhd Self Report Scale Adverse Childhood Experience Prompt Solutions Health & Wellness agreement Patient Questionnaire BIOPSYCHOSOCIAL ASSESSMENT Telehealth Consent Notice of Privacy Practices Declination of Blood Work Consent to Release Confidential Information SCARED-Screen-for-Child-Anxiety-related-Disorders-2 Spence-child-anxiety-scale VanAssesScaleTeacher GAD-7 scale Patient Form Patient Form "*" indicates required fields Required InformationFull Name* First Middle Last Email SexMaleFemaleOtherDate* MM slash DD slash YYYY SOCIAL SECURITY NUMBERMARITAL STATUSMarriedSingleCONTACT NUMBER*AddresssSTREET ADDRESS STREET ADDRESS LINE 2 CITY STATEAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPOSTAL EMPLOYER NAME WORK PHONEEMPLOYER ADDRESSSTREET ADDRESS STREET ADDRESS LINE 2 CITY STATEAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPOSTAL REFERRING PROVIDER REFERRING PROVIDER PHONERESPONSIBLE PARTYIF SAME AS CLIENT CHECK HERE: and skip to next section IF SAME AS CLIENT CHECK HERE: check here Name First Middle Last DATE OF BIRTH* MM slash DD slash YYYY SexMaleFemaleotherSOCIAL SECURITY NUMBERCONTACT NUMBERSTREET ADDRESS STREET ADDRESS LINE 2 CITY STATEAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPOSTAL PRIMARY INSURANCEPOLICY HOLDER NAME* First Last POLICY HOLDER DATE OF BIRTH MM slash DD slash YYYY POLICY HOLDER SOCIAL SECURITY NUMBERCLIENT RELATIONSHIP TO POLICY HOLDER*First ChoiceSecond ChoiceThird ChoiceINSURANCE COMPANY* POLICY NUMBER* Enter group number hereDate MM slash DD slash YYYY SECONDARY INSURANCEPOLICY HOLDER NAME First Last POLICY HOLDER DATE OF BIRTH MM slash DD slash YYYY POLICY HOLDER SOCIAL SECURITY NUMBERCLIENT RELATIONSHIP TO POLICY HOLDERFirst ChoiceSecond ChoiceThird ChoiceINSURANCE COMPANY POLICY NUMBER GROUP NUMBER EFFECTIVE DATE In case of emergency...EMERGENCY CONTACTName* First Last RELATIONSHIP* CONTACT NUMBER*PROMPT SOLUTIONS HEALTH AND WELLNESS LLC. MAY LEAVE MESSAGES ON MY VOICEMAIL REGARDING APPOINTMENT REMINDERS OR REQUEST FOR RETURN CALL. *NO SENSITIVE PATIENT INFORMATION WILL EVER BE SHARED IN VOICE MESSAGES. Yes No I authorize my insurance benefits to be paid directly to Prompt Solutions Health and Wellness. I understand that I am financially responsible for all charges and/or fees not covered or otherwise paid by insurance and it is my responsibility to report any changes in insurance coverage I hereby authorize release of all information necessary to secure payment of benefits. Prompt Solutions Health and Wellness reserves the right to terminate treatment. I authorize the use of this signature on all insurance submissions. In the event my account remains unpaid for a period greater than 90 days, I authorize the release of any required information to a third-party collection agency for the purpose of securing payment for services rendered.E-SIGN* Date* MM slash DD slash YYYY
