Please note that paperwork cannot be saved; once you have started, you will need to complete the form in its entirety in one sitting. Please complete the following at least 24 hours prior to your first appointment.

Adolescent Evaluation Paperwork
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Parents are
Who is responsible for the bill?

Emergency Contact

Office Policy

Please read the below

Element Psychiatry is considered an out-of-network provider. You are financially responsible for charges incurred regardless of insurance reimbursement policies. Payment is due at the time of the visit. Please fill out a Credit Card authorization form to facilitate payments sent to you via email with other set of forms. Statements can be requested at the time of service and will include diagnostic and procedural codes necessary for filing your own insurance claim. At the end of the calendar year, a statement will be provided, upon request, with all appointments and charges to be submitted for insurance reimbursement.

All new patient evaluations require a credit card on file to hold the scheduled time slot. The credit card will be charged if the appointment is not cancelled via email at least 48 hours before the scheduled time of the appointment. For established patients, cancellation or rescheduling is required 24 hours in advance to avoid being charged for the full fee for the reserved appointment time. If the appointment is on a Monday, cancellation is required by the Friday prior. Patients will receive a courtesy email/text reminder, but it is the patient's responsibility to know appointment times.

The charge for a 90 min evaluation or consultation appointment is $525 for both child and adolescent patients and $425 for adult patients (older than 18 years old). Additional charges may be incurred if formal reports or letters are requested. If collaboration is needed outside of sessions in the form of phone calls with the patient or family members responsible for their care or other professionals, a charge will be incurred based on time allocated. The fee for a 45-minute appointment is $175. The charge for medication follow-up appointments ranges from $150 to $100 depending on allotted time.

Payment is due at the time services are rendered. Accounts not paid by the next billing cycle are subject to a service charge of one and one-half percent (1.5%) per month plus a $10.00 administrative fee. Credit cards on file will be charged the day of the appointment or the following day. However, for your convenience cash and checks are accepted at the time of the appointment. Please fill out a Credit Card authorization form to facilitate payments. Appointments are made through Dr. Shah and staff. The office does accept faxes at 732-398-5466.

Please allow 48 hours for processing of medication refills. All requests should be made through your pharmacy and are processed electronically. There will be a $30 refill charge for controlled substance prescriptions that require refills between appointments.

Additionally, there will be a $35 refill charge for ALL prescription refills filled outside of office hours. Dr. Shah is able to provide a three month supply of controlled substances, if permissible by your insurance.

Element Psychiatry is a HIPAA compliant healthcare provider. Please refer to Element Psychiatry Notice of Privacy Practices for information on how your personal health information is used and disclosed. A copy of the privacy practices is available upon request.

Please sign below to indicate that you have read and understood the Office Policy.

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Consent For Treatment

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Reasons For Treatment

Please check any areas below which have worsened due to the patient's current problems.

Medical History

Describe the patient's current sleeping habits.
Has the patient experienced any of the following?

For Females

Is the patient having periods?
Menses is
Is there a possibility that the patient is currently pregnant?
To your knowledge, is the patient sexually active?

For Males

To your knowledge, is the patient sexually active?

Cardiac Risk Assessment

Has the patient fainted or passed out DURING exercise?
Has the patient fainted or passed out AFTER exercise?
Has the patient ever had extreme fatigue associated with exercise (different from other adolescents)?
Has the patient ever had unusual or extreme shortness of breath during exercise?
Has the patient ever had discomfort, pain or pressure in his or her chest during exercise?
Has the patient ever been told he or she has a heart murmur?
Are there any family members who died of heart problems before age 50?
Are there any family members who had an unexpected, unexplained death before age 50?

Psychiatric History

Does the patient have a previous psychiatric or learning difference diagnosis?
Has the patient had previous psychoeducational testing or neurophysical testing?
If so, please provide a copy to our office manager.
Current Medications
Past Psychiatric Medications
Does the patient currently use any substances or have a history of substance abuse? Has the patient ever received treatment for substance abuse?

The patient experiences the following issues regularly

Short Attention Span
Impulsivity (Acts Before Thinking)
Easily Distracted
Wont Follow Rules or Directions
Irritable, Poor Frustration Tolerance
Quick to Anger
Picks on Others, Bullies
Feels Picked On/Has Been Bullied
Teases Others
Deliberately Tries to Annoy People
Easily Angered, Bad Temper
Gets Out of Control
Gets Violent and Aggressive
Cruel to Animals
Fire Setting
Steals
Cries Easily
Gets Inappropriately Giddy and Silly, Mood Seems Elevated at Times
Tiredness/Listlessness
Lack of Interest in Activities
Isolates Self from Others
Sadness
Poor Appetite
Problems Getting to Sleep
Early Morning Awakening
Self-Injurious/Abusive Behaviors
Excessive Sleepiness
Weight Gain/Loss
Worries a Lot
Other Specific Fears (heights, etc.)
Catastrophic Fears
Reluctance to Go to School/Work
Repeated Unwanted Thoughts, Intrusive Thoughts
Rituals (Has to Repeat Same Action)
Hair Pulling or Skin Picking
Excessive Concerns About Body Image or Weight

Social History

Describe the patient's living arrangement
Do the patient's parents work outside of the home?

Education History

Has or does the patient need special services?
Has the patient ever had to repeat a grade?
Has the patient ever been involved in truancy or other legal proceedings?

Family Psychiatric History

Has any family member had any of the following?
Please elaborate on the above as needed

Diet Diary

Please describe your typical diet for one day.

Functional Medicine

Habits & Lifestyle