Mind Matters PsychiatryMD PATIENT INTAKE FORMS | 2020

2620 LONG PRAIRIE ROAD | SUITE 100 FLOWER MOUND, TX 75022

3140 LEGACY DRIVE | SUITE 130

FRISCO, TX 75034

1701 RIVER RUN ROAD | SUITE 1118 FORT WORTH, TX 76107

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| Whose # is this?

| Whose # is this?

Name: _ DOB: _

INTAKE QUESTIONNAIRE

Medical History (check all that apply) □ Allergies/Seasonal □ Anemia □ Arthritis □ Asthma □ Back Pain (Chronic) □ BPH □ Cancer (type) □ COPD/Emphysema □ Diabetes □Type I □Type II □ Disc Disease □ Lumbar □ Cervical □ Fibromyalgia □ GERD / Gastritis □ Gout □ Hearing Loss □ Heart Disease □ Hepatitis □ Hernia □ High Cholesterol □ HIV □ Hypertension □ Hypotension □ Hyperthyroidism □ Hypothyroidism □ Irritable Bowel Syndrome □ Kidney Disease □ Kidney Stones □ Liver Disease □ Lupus □ Migraine Headaches □ Obesity □ Parkinson's Disease □ Seizure Disorder □Sleep Apnea □ Sexually Transmitted Disease □ Stroke/TIA (History of) □Testosterone (Low) □ Traumatic Brain Injury □ □ No Medical Problems

Other Illnesses not listed above: _

Surgical History

□ Appendectomy □ Back □Lumbar □Cervical □ Bariatric Surgery □ Brain □ Cardiac Value □ Cardiac Bypass □ Ear/Nose/Throat □ Gall Bladder □ Gastric Bypass □ Hernia Repair □ Hip Replacement □ Hysterectomy (Part ial) □ Hysterectomy (Total) □ Kidney St ones Removed □ Kidney Remove d □ Knee Replacement □ Prostate □ Rotator Cuff □ Shoulder □ Tubal Ligation □ Wrist □ □ □

Other Surgeries not listed above: ____________________________________________________________

Medications

Please list all medications you take daily including dosages and how often:

Allergies

Please list any drug or non-drug allergies you have:

Name: _ DOB: ________________

Do you smoke cigarettes now?

Have you smoked in the past? Do you use Oral Tobacco?

Do you Drink Alcohol?

□ Yes □ No □ Yes □ No □ Yes □ No

□ Yes □ No

How much per day? _

How much per week? _

Please check all stressors you are experiencing now □ Economic/Financial □Education/School □ Family Conflict □Grief/Loss

□ Legal Problems □Medical Illness □ Work □ Living Situation

□ Social Environment □Substance Abuse □Marital Conflict □Family Disruption due to divorce or separation

□ Personal Injury □Relationship

Please give a brief description of the reason you are here today:

Please check any symptoms you are now experiencing □ Anxiety □ Anger □ Appetite Disturbance □ Behavior Problems □ Decreased Concentration □ Decreased Energy □ Decreased Pleasure and Interest in things □ Depressed Mood □ Feelings of hopelessness, helplessness or worthlessness □ General Stress □ Grief/Loss □ Uncontrolled Fear or Phobia □ Unexplained or chronic pain □ Thoughts of hurting someone else

□ Hallucinations (hearing voices, seeing things) □ Falling Asleep during the daytime □ Impulsiveness □ Insomnia (trouble fall sleep or staying asleep) □ Irritability □ Isolating (staying away from others) □ Mania (unusually hyperactive, talkative) □ Memory Impairment □ Nightmares □ Panic Attacks □ Sexual Dysfunction □ Thoughts of hurting myself □ Rapid weight loss or weight gain

Please list any other symptoms not listed above:

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DOB: _ Name: _

Father: □ Living □ Deceased (Age- )

Brief Description of your Father:

M other: □ Livi ng □ Deceased (Age- )

Brief Description of your Mother:

Si blings: □# Livi ng- □# Deceased-

If you were not raised by your biological parents, please elaborate:

What is your cultural background? (Hispanic, African American, Italian, German, Irish, etc.)

Do you have a history of Substance Abuse? □ Yes □ No Type of substance Quantity Used Frequency of Use

Have you experienced any of the following as a result of your drug or alcohol use? □ Arrests □ Consuming more than intended □ Blackouts □ Driving Under the Influence □ Employment Issues □ Family/Marital Conflict □ Feeling guilty □ Financial problems □ Fighting □ Health Problems □ Increased Tolerance □ Increased tolerance □ Unintentional Overdose

□ Physical Health Problems □ Seizures □ Withdrawal Symptoms

List any other consequences not listed above:

DOB: _ Name: _

Educational History □ Currently in school – Grade _____ □ Less than a high school education □ Graduated from high school □ GED Obtained Highest Grade Completed? _______ □ Associates Degree □ College Degree □ Some College □ Professional Degree □ Technical Degree □ Master's Degree

Employment Status:

□ Full-time □ Part-time □ Unemployed □ Retired □ Disabled □ Homemaker

Employer: How long at current job? _

Occupation: ____________________________________ Are you satisfied with your job? ____________________

Military Experience: □ Never been in the military □ Active/Rank ___________________ □ Parent is active duty military □ Spouse is active duty military □ Retired from military □ Honorably discharged from military □ Veteran □ Medically discharged from military □ Dishonorable discharge

Branch:

□ Air Force □ Army □ Marines □ Navy □ National Guard □ Reserves □ Coast Guard

General Social History: Marital Status:

□ Single/Never married □ Married □ Divorced

□Separated □ Widowed □ Partnership/Serious Relationship

Level of relationship satisfaction:

□ not applicable □ very satisfied □ somewhat satisfied □ dissatisfied

Number of Marriages _ Number of Children:______________

Names and Ages of Children:

DOB: _ Name:

Residential Status:

□ Own □ Rent □ Live w/parents □ Foster Care □ Homeless □ Nursing Home Facility □ Live w/roommate(s)

Housing Conditions are:

□ Excellent □Good □Fai r □ Poor

List members of your current household:

Social Network:

□ Supportive Family □ Friends □ Religious Congregation □ Co-workers □ Online □ Social Services □ Sponsor □ Support Group

Cultural:

□ Caucasian □ African-American □ Hispanic □ Asian □ Native American □ Bi-Racial □ Indian □

Sexual Orientation: □ Heterosexual □ Homosexual □ Bi-Sexual □Transgender/Transitioning

Religion: □ Denomination: __________ □ Participate in religious activities □ Do not participate in religious activities

DOB: _ Name:

2620 Long Prairie Road 3140 Legacy Drive 1701 River Run Suite 100 Suite 130 Suite 1118 Flower Mound, TX 75022 Frisco, TX 75034 Fort Worth, TX 76107

Patient Acknowledgement & Consent Form

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future. To comply with one of the HIPAA requirements, Mind Matters PsychiatryMD is providing you with a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices. Existing Texas law requires (in addition to our attempt to obtain your written acknowledgement, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our professional competence; a review of the entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse / neglect investigation. In some instances, it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another covered entity for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Acknowledgment

Please sign this form below under the heading “acknowledgment” to acknowledge that you have today received a copy of our Notice of Privacy Practices. I acknowledge that I have today received a copy of the Notice of Privacy Practices. __________________________________ Patient Signature (18 & UP) __________________________________ Patient Name (Please Print) __________________________________ Patient or Parent/Guardian Signature

Mind Matters PsychiatryMD

Patient Responsibilities Mind Matters PsychiatryMD is committed to providing quality health care. It is our pledge to provide this care with respect and dignity. In keeping with this pledge and commitment, we present the following Patient Rights and Responsibilities:

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVICES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPPA NOTICE FORM DESCRIBED ABOVE.

You have the right to:

• A personal clinician who will see you on an on-going, regular basis. • Competent, considerate and respectful health care, regardless of race, creed, age, sex or sexual orientation. • A second medical opinion from the clinician of your choice, at your expense. • A complete, easily understandable explanation of your condition, treatment and chances for recovery. • The personal review of your own medical records.

Mind Matters PsychiatryMD does not provide Urgent Care or Emergency/Crisis Services.

Initial Here

Medication Services Your treatment may include taking medication. Prescribing of medication must take into account your personal medical history, other medications that you take, allergies to medicines or other products and your treatment goals. When the practitioner recommends or prescribes any medication, they will inform you of significant benefits and risks, answer any questions, and advise you about regular monitoring of your use of medication, including any necessary periodic laboratory tests.

Initial Here

Minors & Parents Patients under 18 years of age who are not emancipated, and their parents, should be aware that the law may allow parents to examine their child’s treatment records. The practitioner will provide parents with general information about the progress of the child’s treatment, unless the child agrees otherwise. However, there are important exceptions to confidentiality if the practitioners has any reasonable suspicious about the child’s safety. Mind Matter PsychiatryMD will work hard to ensure that parents are rapidly informed about any safety concerns that come to our attention. I agree to stay on-site while services are being rendered for my child.

_Initial Here

SIGN Patient or (Authorized Parent/Guardian Name) Date

PRINT Patient or (Authorized Parent/Guardian Name) Date

Mind Matters Psychiatry MD

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Notice of Privacy & Rights Practices

Notice of Privacy Practices & Rights

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO IT.

Our commitment to your privacy:

We are dedicated to maintaining the privacy of your personal health information as part of providing professional care. We are also required by law to keep your information private. These laws are complicated, but we must give you this important information. This is a shorter version of the full, legally required notice of privacy practices. Please ask if you would like the full version of the notice.

How we use and disclose your protected health information with your consent:

We will use the information about you mainly to provide treatment, and for some other business activities that are called, in the law, health care operations. After you have read this notice we will ask you to sign a consent form to let us use and share your information in these ways. If you do not consent and sign this form, we cannot treat you. If we want to use or send, share, or release your information for other purposes, we will discuss this with you and ask you to sign an authorization form to allow this.

Disclosing your health information without your consent:

There are some times when the laws require us to use or share your information. For example: 1. When there is a serious threat to your or another’s health and safety or to the public. We will only share information with persons who can help prevent or reduce the threat. 2. When required by lawsuits and other legal or court proceedings. 3. If a law enforcement official requires us to do so. 4. For workers’ compensation and similar benefit programs. There are some other rare situations described in the longer version of privacy practices.

Client Initials

Your rights regarding your health information:

1. You may ask us to communicate with you in a particular way or at a certain place that is more private for you. For example, you may ask us to call you at home, and not at work, to schedule or cancel an appointment. We will try our best to do as you ask.

2. You may ask us to limit what we tell people involved in your care or the payment for your care, such as family members and friends.

3. You have the right to look at the health information we have about you, such as your medical and billing records. You can get a copy of these records for a copying fee. Please allow 5-10 business days to fulfill this request.

Mind Matters Psychiatry MD

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4. If you believe that the information in your records is incorrect or missing something important, you may ask us to make additions to your records to correct the situation. You must make this request in writing. You must also tell us the reasons you want to make the changes.

5. You have the right to a copy of this notice. If we change this notice, we will provide you with the new version.

6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way. Also, you may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. We will be happy to discuss these situations with you now or as they arise. If you have any questions regarding this notice or our health information privacy policies, please let we know.

Client Initials

Legal Limits on Confidentiality Protections:

The law protects the privacy of all communications between a patient and a healthcare provider. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by the Health Information Portability and Accountability Act (HIPAA). There are other situations that require only that you provide written, advance consent. However, there are some situations in which we are permitted or required to disclose information without either your consent or Authorization.

• If you are danger to yourself or others. • If we have reasonable suspicious of child or elderly abuse or neglect. • If we are court ordered.

If these situations arise, we will make every effort to discuss them with you before taking any action. While this written summary of exceptions of confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future.

Client Initials

Mind Matters PsychiatryMD

Urine Agreement The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe medications for you.

The long-term use of such substances as opioids (narcotic analgesics), benzodiazepine tranquilizers, stimulants and barbiturate sedatives is controversial because of uncertainty regarding the extent to which they provide long-term benefits. There is also the risk of an addictive disorder developing or of relapse occurring in a person with a prior addiction. The extent of this risk is not certain.

Because these drugs have potential for abuse or diversion, strict accountability is necessary when use is prolonged. For this reason, the following policies are agreed to by you, the patient, as consideration for, and a condition of, the willingness of the provider whose signature appears below to consider the initial and/or continued prescription of controlled substances to treat your condition.

Routine urine or serum toxicology screen may be requested and your cooperation is required. Presence of unauthorized substances my prompt referral for addictive disorder therapy or possible termination from the practice.

You affirm that you have full right and power to sign and be bound by this agreement, and that you have read, understand, and accept all terms.

SIGN Patient/Legal Guardian Signature Date

PRINT Patient Name (Printed)

Provider/Administrative Staff

Mind Matters PsychiatryMD

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Financial Agreement

Adebogun, MD., P.A. is a private psychiatric practice, accepting most insurances and cash payments. Please review our website www.Mind-MattersMD.com for current insurance information or call our office for any questions.

Professional Fees:

• Co-payment or balances are due in full at time of service. • Special financial arrangements must be discussed prior to appointment. • Parents/Guardians are financially responsible for payment of services provided to minors, or other

legal dependents. • Additional fees may include charges for other professional services such as:

o Third-party report writing o Crisis-related telephone interventions o Consulting with other professionals o Legal proceedings requiring representation by the physician will be charged $2,000/first hour

and $500/each subsequent hour, including preparation time and transportation. All fees must be remitted prior to service.

o Preparation of records or treatment summaries $25 for administrative processing. Attorney request for records: $50/first page, $20/each subsequent page. All fees must

be remitted prior to service. Upfront, disability and FMLA paperwork will be assessed $125/form requiring

completion. Any additional paperwork will be subject to fees. o No personal checks are accepted for payment of services.

Payment for Services:

It is my responsibility to know what services are covered by my insurance plan. I have carefully reviewed the section in my insurance coverage that describes mental health services. I will call my plan administrator with any questions. I will pay for any services I receive that are not covered or denied by my insurance plan.

I will provide full and accurate insurance information in advance of my appointment or will pay for the appointment on a self-pay basis. I will present my insurance card at the time of my appointment. I will provide updated insurance information prior to my appointment in case of any changes.

I understand that I, not my insurance company, am responsible for full payment of my fees. I understand that insurance billing is provided by my healthcare provider as a courtesy, but I remain the responsible party. I understand that, if after 90 days, my insurance company has not responded, I will receive a statement. I agree to pay my balance in full at that time. I understand that I will be reimbursed promptly if and when the insurance payment arrives.

I understand that I am responsible for payment of any balances on my account.

Mind Matters PsychiatryMD

Policy for Missed Appointments and Cancellations:

Appointment times are reserved exclusively for me. To avoid any missed appointments or late cancellation fees, I will call 24 hours in advance to make any changes to my appointment.

I agree that I must give proper notification to cancel an appointment to avoid late cancellation or missed appointment fees. I agree to call at least 24 hours in advance to cancel or change my appointment.

Appointment no-shows will be charged a fee of $150 for practitioners, and a fee of $75 will be charged for counselors. Appointments cancelled less than 24 hours for practitioners will be charged a fee of $100 and $50 for counselors.

BY SIGNING THIS AGREEMENT, I CONFIRM I HAVE READ, UNDERSTAND AND AGREE TO ABIDE BY ALL ITEMS AND TERMS SET HEREIN.

PRINT Printed name of patient or authorized parent/legal guardian

SIGN Signature of patient or authorized parent/legal guardian

/ /2020

Mind Matters PsychiatryMD

We routinely use Texas Prescription Monitoring to guide our

Prescription Practices.

We do not refill Controlled Substances when scheduled appointments are

missed.

We will not resend Controlled Substance prescriptions to a different

pharmacy other than one on our record.

It is your responsibility to inform the office of a change of address or

insurance change that requires a Preauthorization for your appointment and Prescription Coverage.

Otherwise, a cash rate will be applied if insurance verification cannot be completed for the scheduled appointment.

BY SIGNING THIS NOTICE, I CONFIRM I HAVE READ, UNDERSTAND AND AGREE TO ABIDE BY ALL ITEMS AND TERMS SET HEREIN.

PRINT Printed name of patient or authorized parent/legal guardian

SIGN Signature of patient or authorized parent/legal guardian

Thanks for your time and effort in completing this paperwork!