Ability Behavioral Health

Nobody reads this form as you type it. Our team reviews forms during office hours (Monday to Friday, 9am to 5pm). If you need help sooner, call or text 988, or call 911.

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About you

First name *

Last name *

Date of birth *

Appointment date and time, if known

Who are you seeing?

What kind of visit is this?

Intake with a providerMedication managementTherapy or counselling onlyNot sure

Gender

FemaleMaleOtherPrefer not to answer

Ethnicity

African-AmericanAmerican Indian / Alaska NativeAsianCaucasianHispanic / LatinoMulti-ethnicityNative Hawaiian / Pacific IslanderOtherPrefer not to answer

Relationship status

SingleMarriedIn a relationshipSeparatedDivorcedWidowedOther

Highest level of education

Occupation

Are you currently on disability or SSI?

NoYes

If yes, please specify

How we reach you

Street address *

City *

State *

ZIP *

Cell phone *

Home phone

Work phone

Emergency contact name *

Their relationship to you *

Their phone *

Their email

Your care team

Primary care physician — name and phoneLeave blank if you do not have one.

Psychiatrist — name and phoneLeave blank if you do not have one.

Therapist or counsellor — name and phoneLeave blank if you do not have one.

Pharmacy name, address and phone

How did you hear about us?

Primary care physicianPsychiatristTherapistInsurance directoryFriend or familyOnline searchOther

I authorise Ability Behavioral Health to release a summary of my visit and treatment plan to the members of my care team selected below, to help coordinate my care. I understand I can revoke this at any time in writing.

Share my treatment summary with

My primary care physicianMy psychiatristMy therapistNobody — do not share

Insurance and billing

Are you self-pay (not using insurance)?

NoYes

Does any of this apply?

EAP (employee assistance)Workers compensationLegal caseDisability claimNone of these

Insurance company

Insurance phone

Member ID

Group number

Policy holder name

Policy holder date of birth

Policy holder is

MyselfMy spouseMy parentOther

If you would like us to be able to discuss your appointments and account with someone else, list them below. We cannot accept this by phone.

Who may we speak to about your appointments and account?Name, relationship and phone number. Leave blank if nobody.

What brings you in

In your own words, why are you here today? *Include how you feel about your mental health and anything else relevant.

What is currently worrying you or causing stress?For example work, relationships, money, school.

Who do you live with?

AlonePartnerPartner and childrenParentsShared apartment or dormGroup or community homeOther

Where were you raised?

Who raised you?

Were there any problems with your birth or early childhood?

NoYes

Have you experienced any traumatic events?You do not have to give details. Telling us is enough for us to provide trauma-informed care.

NoYes

Anything you would like us to know about that

Any legal problems, now or in the past?

NoYes

Brief description

Mental health history

Psychiatric problems in your familyParents, siblings, children, grandparents, aunts and uncles. Note who and what, as best you know.

Anyone in your immediate family who has diedWho, and roughly when. Leave blank if not applicable.

Psychiatric hospitalisationsReason, hospital and rough dates. Leave blank if none.

Have you had psychotherapy before?

NoYes

With whom?

Have you had either of these?

TMS therapyECTNeither

If so, what was the outcome?

Psychiatric medications, past and presentName, dose, roughly when you took it, and whether it helped or caused side effects. One per line.

Substance use

These answers are confidential and are used only to keep your treatment safe, particularly around which medications are suitable for you.

Substances you use or have usedInclude caffeine, tobacco, vaping, alcohol and any drugs. For each: what, how much, how often, and when you last used it.

Have you had treatment for alcohol or drug use?

NoneOutpatientInpatientDetoxAA or NAMedication-assisted treatment

If so, when and where?

Medical history

Do you have, or have you ever had, any of these?

AnemiaAnginaAsthmaCancerCataractsColitisCrohn's diseaseDiabetesEmbolismEmphysemaEpilepsy (seizures)GoiterHeart murmurHeart problemsHepatitisHigh blood pressureHigh cholesterolHIV / AIDSHypothyroidismJaundiceKidney diseaseKidney stonesLeukemiaPneumoniaPsoriasisPulmonary diseaseRheumatic feverStomach or peptic ulcerStrokeTuberculosisSleep apneaHead injuryChronic painNone of these

Any other medical conditions

Allergies to medications or other substancesWhat you react to and what happens. Leave blank if none.

Other medications you take nowIncluding anything over the counter or herbal.

Surgeries and non-psychiatric hospital staysReason and rough dates. Leave blank if none.

Height

Weight

How you have been feeling

Over the last 2 weeks, how often have you been bothered by any of the following?

Little interest or pleasure in doing things

Not at allSeveral daysMore than half the daysNearly every day

Feeling down, depressed or hopeless

Not at allSeveral daysMore than half the daysNearly every day

Trouble falling or staying asleep, or sleeping too much

Not at allSeveral daysMore than half the daysNearly every day

Feeling tired or having little energy

Not at allSeveral daysMore than half the daysNearly every day

Poor appetite or overeating

Not at allSeveral daysMore than half the daysNearly every day

Feeling bad about yourself, or that you are a failure, or have let yourself or your family down

Not at allSeveral daysMore than half the daysNearly every day

Trouble concentrating on things, such as reading the newspaper or watching television

Not at allSeveral daysMore than half the daysNearly every day

Moving or speaking so slowly that other people could have noticed — or the opposite, being so restless that you have been moving around a lot more than usual

Not at allSeveral daysMore than half the daysNearly every day

Thoughts that you would be better off dead, or of hurting yourself in some way

Not at allSeveral daysMore than half the daysNearly every day

Support is available right now

Thank you for telling us. You do not have to wait for your appointment.

Call or text 988 Call 911

You can also text HOME to 741741. Please keep filling in the form if you can — but use these numbers if you need someone now, because nobody is reading this as you type.

Still thinking about the last 2 weeks:

Feeling nervous, anxious or on edge

Not at allSeveral daysMore than half the daysNearly every day

Not being able to stop or control worrying

Not at allSeveral daysMore than half the daysNearly every day

Worrying too much about different things

Not at allSeveral daysMore than half the daysNearly every day

Trouble relaxing

Not at allSeveral daysMore than half the daysNearly every day

Being so restless that it is hard to sit still

Not at allSeveral daysMore than half the daysNearly every day

Becoming easily annoyed or irritable

Not at allSeveral daysMore than half the daysNearly every day

Feeling afraid, as if something awful might happen

Not at allSeveral daysMore than half the daysNearly every day

And thinking about the last month:

How often have you been upset because of something that happened unexpectedly?

NeverAlmost neverSometimesFairly oftenVery often

How often have you felt unable to control the important things in your life?

NeverAlmost neverSometimesFairly oftenVery often

How often have you felt nervous and stressed?

NeverAlmost neverSometimesFairly oftenVery often

How often have you felt confident about your ability to handle your personal problems?

NeverAlmost neverSometimesFairly oftenVery often

How often have you felt that things were going your way?

NeverAlmost neverSometimesFairly oftenVery often

How often have you found that you could not cope with all the things you had to do?

NeverAlmost neverSometimesFairly oftenVery often

How often have you been able to control irritations in your life?

NeverAlmost neverSometimesFairly oftenVery often

How often have you felt that you were on top of things?

NeverAlmost neverSometimesFairly oftenVery often

How often have you been angered by things outside of your control?

NeverAlmost neverSometimesFairly oftenVery often

How often have you felt difficulties were piling up so high that you could not overcome them?

NeverAlmost neverSometimesFairly oftenVery often

Has there ever been a period when you were not your usual self? Tick anything that applied during that time.

During that period

I felt so good or hyper that others said I was not myselfI was so irritable I shouted at people or started argumentsI felt much more self-confident than usualI slept much less and didn't miss itI was much more talkative or spoke fasterThoughts raced and I couldn't slow my mind downI was so distracted I had trouble staying on trackI had much more energy than usualI was much more active than usualI was much more social or outgoing than usualI was much more interested in sex than usualI did things that were unusual, excessive, foolish or riskySpending money got me or my family into troubleNone of these

Did several of those happen during the same period?

NoYesNot applicable

How much of a problem did that cause?

No problemMinorModerateSerious

Has a blood relative had bipolar or manic-depressive illness?

NoYesNot sure

Has a health professional ever told you that you have it?

NoYes

Policies and consent

Policies and financial agreement

Missed appointments

Please give us 24 hours notice during the business week to cancel or change an appointment. Missed appointments are charged to you directly, and the fee must be paid before your next visit.

Medication refills

Book your follow-up so that you see your provider before your medication runs out. Refills are not authorised without an appointment. If a visit was cancelled for a genuine emergency we will bridge your refill until the next available appointment.

Privacy in our offices

Photography, recording conversations, or similar activity in the office will result in discharge from the practice.

Financial policy

Payment of your share is due at the time of service. If your insurer requires pre-authorisation and it is not in place, you are responsible for the full fee. Because of our contracts with insurers, we are unable to provide services without charging the portion for which you are responsible.

Overpayments are held against future services unless the amount is at least $20 and you ask for a refund.

You also agree that

You are responsible for your entire fee, and you authorise us to bill your insurer directly and receive payment for services provided.
If your account becomes delinquent and is passed to an attorney, you are responsible for the attorney fees and court costs.
You authorise us to send your treatment plan to your insurer and exchange information relating to your treatment.
Ability Behavioral Health is a group of independent practitioners, and you consent to the clinicians within the group exchanging information to support your treatment.
You may revoke this consent at any time in writing, and you may ask for copies of everything you signed.

Privacy

Your health information is disclosed only where you or your representative have authorised it; for treatment, payment or healthcare operations; where you have had the chance to agree or object; or where the law otherwise permits or requires it.

I have read and agree to the policies and financial agreement *

Consent for treatment

I have received the patient information packet, including Patient Rights and Responsibilities and the Privacy Practices notice, and I accept these policies. I may request a copy at any time.

I understand that treatment offers no guarantees. Working with my provider should help with the concerns I bring, but things may get harder before they get easier. I will probably need to practise new approaches outside appointments, and if I do not, treatment will be less effective.

I agree to cooperate with my provider, or to discuss any reason I cannot, and to ask questions so that my goals are clear.

Treatment ends when my concerns are resolved, and I may end it at any time. I agree to tell my provider first so we can discuss the risks of stopping early.

My provider may also end treatment if we are not making progress or the working relationship becomes too strained. If I can no longer pay, my provider will suggest other options and I will make every effort to follow them.

I have read and agree to the consent for treatment *

Controlled substance agreement

This applies if I am prescribed a controlled medication such as a benzodiazepine or a stimulant, because my condition has not been managed adequately without one. The aim is to improve how I function; it is unlikely to remove the condition entirely.

I will take the medication only as prescribed, and will not add sedatives, alcohol or other medications without my provider approving it first.
Prescriptions are issued during business hours on the agreed schedule, and are not called in to the pharmacy.
I will not seek or accept controlled medication from anyone else. That includes other providers, medication borrowed from family or friends, and any street drugs.
Refills are written prescriptions only and will not be given prior to 30 days. I must be seen at least every three months, or sooner if my provider recommends it. Two missed appointments are grounds for dismissal from the practice.
Lost medication is not replaced. A police report is required for anything lost or stolen.
My provider may stop this medication at any time, and is required by law to report controlled substances dispensed to me to the state Prescription Drug Monitoring Program.

I understand that if I am discharged under this agreement and have a medical emergency, I should call 911 or go to the nearest emergency room.

I have read and agree to the controlled substance agreement, if controlled medication is prescribed to me *

Typing your name below is your electronic signature. It has the same effect as signing on paper. If you would rather sign on paper, call 240-294-6682 and we will post you a packet.

Type your full legal name to sign *

Date *

If signing for a minor or dependent adult, type your name and relationship

Everything I have entered is accurate and complete to the best of my knowledge *

ABILITY BEHAVIORAL HEALTH

About you

How we reach you

Your care team

Insurance and billing

What brings you in

Mental health history

Substance use

Medical history

How you have been feeling

Support is available right now

Policies and consent

Policies and financial agreement

Missed appointments

Medication refills

Privacy in our offices

Financial policy

You also agree that

Privacy

Consent for treatment

Controlled substance agreement

Your Mental Health is Our Top Priority