New Patient Intake Form – MinorsDrCortman2021-05-04T20:53:41+00:00 Please enable JavaScript in your browser to complete this form. - Step 1 of 9Today's Date: *Patient/Minor's Legal Name: *FirstLastPreferred nickname:Preferred pronoun:Date of Birth: *Age: *Address: *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary Phone: *Alternate Phone:Email *Please note: Email correspondence is not considered to be a confidential medium of communication.Referred by:Name of present physician:Name of person completing this form: *Parent/Guardian #1 Name: *FirstLastAddress: *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone: *Relationship to patient: *Parent/Guardian #2 Name:FirstLastAddress:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone: Relationship to patient:Who does the patient/minor live with? *NextInsurance policy holder information:Name: *FirstLastDate of Birth: *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCurrent Medications:Name of Medication #1Dosage *Frequency *Route *Name of Medication #2Include name, dosage, frequency and route.Dosage *Include name, dosage, frequency and route.Frequency *Include name, dosage, frequency and route.Route *Include name, dosage, frequency and route.Name of Medication #3Dosage *Frequency *Route *Please upload a separate page if more room is needed. Click or drag a file to this area to upload. Over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements:Name of Supplement #1Dosage * Frequency *Route *Name of Supplement #2Dosage * Frequency *Route *Name of Supplement #3Dosage * Frequency *Route *Please upload a separate page if more room is needed. Click or drag a file to this area to upload. If you would like to upload a copy of your insurance card here, please do so. (If you do not upload those here, you will need to submit a copy to the office in order to be scheduled for your initial appointment.) Click or drag a file to this area to upload. Name of school: *Grade: *List any special area of interest or hobbies (art, books, physical fitness, etc.): *Briefly describe the reason for seeking counseling for your child: *NextPlease check any of the following symptoms your child may be experiencing: *IrritabilityHopelessPoor sleepCryingAngerEnergeticRacing thoughtsTalkativeInappropriate sexual behaviorsWorryRestlessScaredObsessive thoughtsOutburstsFightsTruancyDestruction of propertyFire settingHyperactiveImpulsiveDifficulty with attentionNever tiredNightmaresSocial/language impairmentHearing voicesSeeing thingsParanoiaDelusionsDissociationHarming themselves intentionallyAttempted suicideHarmed othersAbnormal eating behaviorsDistorted body imageSocial withdrawalHas your child ever been hospitalized for psychiatric reasons? *YesNoIf yes, when and where? *Has your child ever had outpatient treatment by a psychiatrist? *YesNoIf yes, when and by whom? *Has your child ever received counseling or psychotherapy in the past? *YesNoIf yes, when and by whom? *Are you concerned about your child consuming alcohol or recreational drugs? *YesNoIf yes, please provide details: *NextConfidentiality Form, Financial Responsibility and Insurance/Medicare AgreementIn accordance with the Health Insurance Portability & Accountability Act of 1996 ("HIPAA") which is a Federal Law, it is the policy of Dr. Cortman and/or members of his staff to not release confidential and/or unauthorized information. Dr. Cortman and/or members of his staff may leave medical information pertaining to my appointments on the telephone number(s) and/or by using the address provided on the intake information form. You will assume responsibility to notify Dr. Cortman and staff whenever this information changes. If you authorize healthcare information to be released to ANYONE ELSE, please complete the following:I release my medical information to:Name/RelationshipI release my medical information to:Name/RelationshipIn exhange for Dr. Cortman's and/or a member of his staff's agreement to prov ide professional serices, YOU AGREE TO PAY THE FEES for such services. Payment is due at the time services are provided unless other arrangements have been agreed to in writing prior to the services being provided. Availability of insurance coverage or the agreement of another person to be responsible for the payment of fees for services do not relieve you (or you on behalf of your minor child) of responsibility for the payment due. IF USING INSURANCE AND/OR MEDICARE, you authorize the release of any medical or other information necessary to process the claims for services provided and payment of medical benefits to Dr. Cortman and/or a member of his staff for the services provided. You AGREE TO PAY INTEREST at the rate of eighteen percent (18%) per year on any balance due which you fail to pay within sixty (60) days. You further agree that you will pay the costs of collection, including attorney's fees, if Dr. Cortman and/or a member of his staff must take any action to collect an overdue payment. THIS AGREEMENT SHALL REMAIN IN EFFECT until you (or your minor child) professional services rendered have been paid in full.By typing my name below, I agree to all of the above. *Print nameDate *Next24 Hour Cancellation PolicyIF YOU NO-SHOW OR CANCEL YOUR APPOINTMENT WITH LESS THAN 24 HOURS NOTICE, YOU WILL BE CHARGED $100.00 FOR THE MISSED APPOINTMENT.You will never be charged for a cancellation if it is made at least 24 hours in advance of your scheduled appointment time. Reason for this policy: Notifying us of your intention to cancel or reschedule 24 hours in advance gives us an opportunity to schedule someone else for that time slot. This is important because others may be on a wait list or may also be looking for an opportunity to reschedule for a different time. As much advance notice as possible is always appreciated.This cancellation policy is standard in the medical and mental health fields and will be strictly enforced. On occasion, there will be understandable reasons for msising appointments, but exceptions to this policy will be rare.Teleheath SessionsDue to the Coronavirus outbreak, we are currently only offering telehealth sessions. Most insurance providers provide the same coverage for telehealth appointments as they would for comparable in-office visits. However, some plans may still refuse to cover telehealth visits, as this is is up to the insurance provider. We are in-network for Medicare and out-of-network for all other insurances. Although we accept most major insurance plans, we encourage telehealth patients to check with their insurance companies about telehealth coverage before their appointments. We DO NOT accept Medicaid, even as a secondary insurance.Third party breaches are possible and these breaches are the largest associated risk with using telehealth services. We continue to follow ethical standards for privacy and confidentiality when using telehealth services. There should be no additional cost as a user of telehealth unless you have limited internet usage in your home. Please ensure the Wi-Fi connection you are using for telehealth services is password protected and secure. Telehealth services vary state by state. If you currently live outside of the state of Florida, your session may not be covered by insurance. You must let our staff know if you are not in Florida prior to scheduling an appointment. There are some potential benefits and risks of telehealth (e.g. miscommunication, missed non-verbal cues, household noise or interruptions, increased flexibility, convenience) that differ from in-person sessions. It is important during telehealth sessions that your clinician has a phone number where you can be reached if services are disconnected.Please note: A session is between 45-55 minutes in length. Please sign below to indicate you have read, understand, and agree. *FirstLastDate *NextNotice of Privacy Practices AcknowledgmentUnder the Health Insurance Portability and Accountability Act of 1996 ("HIPAA "), you have certain rights to privacy regarding your protected health information. Your information can and maybe used to:- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly. - Obtain payment from third-party payers.- Conduct normal healthcare operations, such as quality assessments and physician certifications.Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information is available upon request this organization has the right to contact its notice of privacy practices from time to time but you may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.If you have been referred by your physician, please read and complete one of the following options:By checking this box I consent to send a one time letter to my physician confirming that I have met with a therapist. No further correspondence will be sent without your consent.By checking this box I do not consent to send a confirmation letter to my physician.Name *FirstLastDate *NextPatient Health Questionnaire - 9 (PHQ-9) Modified for AdolescentsHow often have you been bothered by each of the following symptoms during the past two weeks? For each symptom select the answer that best describes how you have been feeling.Feeling down, depressed irritable or hopeless? *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayLittle interest or pleasure in doing things? *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayTrouble falling asleep, staying asleep, or sleeping too much? *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayPoor appetite, weight loss, or overeating? *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayFeeling tired or having little energy? *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayFeeling bad about yourself - or feeling that you are a failure, or have let yourself or your family down? *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayTrouble concentrating on things like school work, reading, or watching TV? *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayMoving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you were moving around a lot more than usual? *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayThoughts that you would be better off dead, or of hurting yourself in some way? *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayIn the past year have you felt depressed or sad most days, even if you felt okay sometimes? *YesNoIf you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?Not difficult at allSomewhat difficultVery difficultExtremely difficultHas there been a time in the past month when you have had serious thoughts about ending your life? *YesNoHave you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt? *YesNoIf you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room or call 911.NextGAD-7 AnxietyOver the past two weeks, how often have you been bothered by the following problems?Feeling nervous, anxious, or on edge *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayNot being able to stop or control worrying *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayWorrying too much about different things *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayTrouble relaxing *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayBeing so restless that it is hard to sit still *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayBecoming easily annoyed or irritable *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayFeeling afraid, as if something awful might happen *Select Your ResponseNot at allSeveral daysMore than half the daysNearly every dayIf you selected any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?Not difficult at allSomewhat difficultVery difficultExtremely difficultNextCredit Card Authorization FormPatient name: *FirstLastName on card: *FirstLastCredit Card #: *Credit card type: *VisaMasterCardAMEXDiscoverExpiration: *Security Code: *Billing Address for card: *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBy typing my name below, I hereby authorize Dr. Cortman & Associates to charge my credit card for services rendered.Signature: *FirstLastDate: *Submit