NEW

PATIENT REGISTRATION FORM

• First Name: ___________ • Middle Name: ____________ • Last Name____________________
• Date of Birth: _________
• Sex: M / F
• Marital Status: _______________________________________
• Street Address: _______________________________________
• City, State, Zip: _______________________________________
• Email Address: _______________________________________
• Phone Numbers ( May we leave a message? Y or N ):
Home: ____________________
Work: _____________________
Cell: ______________________


MEDICAL AND REFERRAL INFORMATION

Name of Primary Care Physician: ____________________________________________
Telephone Number of Primary Care Physician: _________________________________
Address of Primary Care Physician: __________________________________________
May I contact your health care provider in the future? __________________________
Who referred you to our practice? __________________________________________
Please list names and contact information for any doctors that have been significantly involved in your care over
the last ten years.
*__________________________________________________________________________
*__________________________________________________________________________
*__________________________________________________________________________
*__________________________________________________________________________

Emergency Contact
Who should we contact in case of emergency?_____________________________________
Relationship to you? __________________________________________________________
Home and Cell Phone Numbers: _________________________________________________

Medical History
Current medical problems: _____________________________________________________
Past medical problems (with dates):
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________

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Past surgical history (with dates):
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
Family Medical/Mental Health/Drug/Alcohol History (siblings, parents, children, aunts/uncles):
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
Current medications (name/dosage/frequency/reason for taking the medication):
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________
• ___________________________________________________________________


Allergies to medications and reaction: __________________________________________
Supplements, vitamins, or herbs: ______________________________________________
Exercise (frequency & type): __________________________________________________
Tobacco use: ______________________________________________________________

Drug or alcohol use (include what drugs, amount and frequency): __________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Current Issues (include symptoms & duration):___________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

A U T H O R IZ A T IO N O F R E L E A S E P A T IE N T H E A L T H IN F O R M A T IO N F O R T R E A T M E N T ,
B IL L IN G O R H E A L T H C A R E O P E R A T IO N S

I understand that Glendale Mental Health reserves the right to change their notices and practices, and
I will be given new notification if this occurs.

I understand that I have the right to request restrictions as to how my health information may be used or disclosed
to carry out treatment, payment, or healthcare operations. I understand that I may revoke this consent in writing. I
understand that the Glendale Mental Health staff are not required to adhere to these restrictions requested in the
event of a potentially life threatening emergency.

Records may be needed in order to process a claim for medical services. I authorize providers at Glendale Mental
Health to release information needed for billing purposes to entities that may provide services pertaining to my
physical visit, such as laboratories. I understand that by signing below, I am authorizing the release of all or part
of my medical record for the purpose of billing, treatment, or pertinent healthcare operations.

Patient/Guardian Signature_____________________________ Date ____________

Patient/Guardian Printed Name_________________________________

I authorize Glendale Mental Health to discuss my psychiatric/mental health care to any and all past or present
treating health professionals as well as the following (please list any friends or family members that you may
want to have included in your treatment):

Names: ______________________________________________

I am aware that this information may pertain to my psychiatric condition and/or treatment of substance abuse. I
execute the release of this information.

Patient/Guardian Signature____________________________ Date ____________

Patient/Guardian Printed Name_________________________________

N O T IC E O F O F F IC E P O L IC IE S , P R O C E D U R E S A N D C O N S E T O F T R E A T M E N T

Travelling Out of State:

Should you leave the state, your provider will not be able to continue to prescribe medication. If you are going on
vacation, please call your provider with enough notice so that he or she can give you enough medication prior to
your trip.

Privacy and Release of Information:

Services that you receive in this office are confidential, except in the following circumstances listed below:

· Threats of harm to yourself or others.

· Abuse of a vulnerable adult, child, or developmentally disabled person.
· A court order to release information.
· Subpoena of treatment records by an attorney. If you do not want this information released, you must obtain a
protective order from the court within fourteen days of the request.
· If you will be submitting a claim to your health insurance, we may be required to prove information to your
health plan, including some or all of your record of treatment, in order for your carrier to pay for services. By
signing this form, you consent to release this information to your health plan.
· If you are involved in a child custody litigation at any time in the future, the court may order release of
information about your treatment.

In circumstances other than these, I will not release information about your treatment without your authorization.

Patient Records:

A secured electronic record is kept of services you receive in this office. You have the right to see the record and
receive a copy of it upon request. You may ask that factual errors in the record be corrected. You may authorize,
in writing, that copies of the record be released to entities you designate. Under certain circumstances where
seeing the record may put a patient or other person at risk, I may redact certain information in the record and/or
require that you review the record in consultation with another healthcare provider.

Methods of Communication and Execution of Clinical Care:

You can generally expect a return call within one business day that a message is left. Should there be an
emergency or concern for imminent health or the safety of yourself or another person, please call 911 or go to the
nearest emergency room immediately.

Hospitalization:

Should you require hospitalization, please go to your nearest emergency room or dial 911. Staff at Glendale
Mental Health do not have admitting privileges at the hospital. Should you need to be admitted, they can
communicate with the inpatient treatment team to let them know about your prior treatment.

Secure Messaging:

Patients are offered the opportunity to use secure messaging (similar to email) with providers through patient
fusion. Should a patient elect to do this, please keep in mind that this service should only be used for non-
emergent matters as messages are not checked daily. This service is HIPAA compliant.
Should there be an emergency, the best option is call 911 or go to the nearest emergency room.

Patient Signature_________________________________________________ Date_____________

Patient Printed Name______________________________________________

Consent for email/text messages:

I understand that Glendale Mental Health cannot guarantee the confidentiality of any email communications and
will not be liable for improper disclosure of confidential information and/or breaches in confidentially caused by
me or a third party. I understand that Glendale Mental Health has no control over the security or management of
my individual email service provider and cannot guarantee that information will not be intercepted, altered, or
read by an unintended recipient.

I further understand and agree that: email will not be used in emergencies and I agree to call 911 in the event of an
emergency, emails will be answered within a maximum of 7 business days and that a prompt reply may not be
available during weekends or holidays, I must include my full name and date of birth in every email message I
send, I understand and agree that providers may choose to stop electronic communications with me at any time,
and I understand that the confidentiality of my individually identifiable health information may be compromised
when such is sent through email. I agree to the requirements listed above and hereby voluntarily request and
consent to communicate with physician and/or office personnel by email or text.

Patient Signature_________________________________________________ Date_____________

Patient Printed Name______________________________________________

Insurance Benefits and Patient Responsibilities for Fees:

Glendale Mental Health does not participate as a contracted provider for any insurance company and does not do
insurance billing, but can provide you with a detailed receipt that you may submit to your insurance company.
They may or may not then provide some direct reimbursement to you. Payment is due at the time the service is
rendered. Glendale Mental Health accepts cash, check, and major credit cards.

Cancellation Notice, Cancellation Fee and No-Show Policy:

Our clinic requires 24 business hours notice for cancellations. Therefore, cancellations for a Monday visit must
be made early the Friday prior. Missed visits, no-shows or late cancellations will be charged the full fee of the
scheduled session (for new patients as well as follow up patients).

Phone calls longer than ten minutes will be billed at the next highest rate level (i.e. less than thirty minutes will be
billed for thirty minutes, greater than thirty minutes but less than fifty minutes will be billed at fifty minutes). Any
outstanding fees will be charge to the card designated on this form.

Fee Agreement:

Description of Procedure Minutes Fee

60-Min Initial Consultation 60 $380
90-Min Initial Extended Consultation 90 $560
15-Min Medication Management Visit 15 $95
25-Min Medication Management Visit 25 $180
50-Min Medication Management Visit 50 $380
50-Min Psychotherapy Visit or Session 50 $380

Forms/Letters: $50 (this may vary based on the amount of time involved)

I understand and accept the terms of the Fee Agreement, Cancellation Fee, and No-Show Policy as outlined
above and authorize Glendale Mental Health to charge my credit card accordingly.

Credit Card Number: _____________________________________________________
Credit Card Type: ________________________________________________________
Expiration Date: ________________ Security Code:_____________________________

Name on Credit Card: ____________________________________________________
Billing Street Address: ____________________________________________________
Billing City, State, Zip: ____________________________________________________
Phone Number: _________________________________________________________
Email: _________________________________________________________________
Signature: ______________________________________________________________
Date:_____________________