| New Patient Forms and Releases |
We are honored that you have chosen us to partner with in your treatment and are looking forward to meeting you. The forms below will provide information on your background and history so we can spend more of your first visit focusing on your current struggles and concerns. Please print the entire column of forms beneath the patient heading appropriate to your visit. Completed forms MUST be brought to the initial appointment. If you do not bring the completed forms to your visit, the time will need to be spent verbally acquiring the information contained in the forms, requiring a second appointment to finish the evaluation process. The completed forms allow us to complete an evaluation in one visit and enable us to begin implementing your treatment plan immediately. |
| ADULT (over 18) Adult New Patient Forms |
| ADOLESCENT (13-18 y.o.) Adolescent New Patient Forms Vanderbilt Parental Assessment Vanderbilt Teacher Assessment |
| CHILD (10 - 12 y.o.) Child New Patient Forms Vanderbilt Parental Assessment Vanderbilt Teacher Assessment |
| Stonebriar Psychiatric Services, P.A. 972-335-2430 |
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3550 Parkwood Blvd. Suite 705
Frisco, Texas 75034
Frisco, Texas 75034
| We are not Medicare patients may not submit for reimbursement, so eligible for it will also need to complete this Medicare Private Contract |
Were you referred to our office by a medical professional or a counselor? If so, please download and complete the Release of Information so that we can communicate with them. Be sure to initial all blanks, and to sign and date the form. This form should also be completed for each previous psychiatrist, counselor or inpatient or residential facility you have had treatment from so that we can request records. |
| MARITAL or COUPLE'S Each partner needs to complete the following: Marital History Form Medical and Social History Personality Profile Adult ADHD Self-Report Mood Disorders Screen Cage & Scoff Screens Office Policy and Consent for Treatment |
| Those covered by Medicare will also need this form Medicare Private Contract |
should complete: Personality Profile An adult family member should complete the following on behalf of the family: Family Questionnaire Office Policy and Consent If you have had previous family therapy, it would be useful to get your previous records. To facilitate this, have each individual over the age of 18 complete the following (parents will list children under the age of 18 on parent's form): Release of Information |
| Those covered by Medicare will also need this form Medicare Private Contract |
| Need to pre-pay an appointment? If you are pre-paying your appointment, you may do so in three ways. You may fax a completed Credit Card Authorization (above in the green box), along with a copy of the card, - front and back - to our secure fax at 972-852-1812. Make sure to check the box next to pre-pay and enter the date of your appointment. Complete the remainder of the form for your subsequent visits. or You may click on the Pay On Account button on the left of the screen to pay by credit card, debit card or bank draft through Pay Pal (you do not need a Pay Pal account) and may use this feature at your convenience - 24/7. or Stop by our office and you may pay by cash, or credit card. |
Complete a release of information for your previous health care professionals, so that we can request records.