Date of scheduled initial appointment *

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

Best Phone Number to Reach You *

(###)

###

####

Emergency Contact's Phone Number *

(###)

###

####

Please check all of the following: *

I have reviewed and understand the Office Policies and Notice of Privacy Practices (first link under 'Patient Forms').

I understand that I must keep an active credit card/HSA/FSA card on file. I am responsible for updating this card when appropriate. If I’m a self-pay patient, I understand that my card will be automatically charged after appointments. If I'm using BCBS PPO or Seton Insurance, I am aware that Austin PsychCare will submit the claim, that I am financially responsible for whatever insurance does not cover (i.e., copays, deductibles, inactive insurance policies, policy exclusions for mental health, HMO plans), and I understand that my chosen payment method will be automatically charged. I am aware the Austin PsychCare does not accept any Medicare/Medicaid insurance plans. *

I have read and understand policies regarding fees and financial arrangements.

I understand that appointment cancellations require 24 hours’ notice via phone during normal business hours. Monday cancellations must occur before noon the previous Friday. I understand that the office does not accept cancellation requests via e-mail or weekend voicemails. If I do not follow the cancellation policies, I understand that I am responsible for the provider’s full out-of-pocket fee, even if I use insurance. *

I have read and understand policies regarding cancellations/missed appointments

I understand that if I'm seeking a new ADHD diagnosis, I will need formal neuropsychiatric testing to confirm the diagnosis. I understand that Austin PsychCare does not prescribe controlled substances such as benzodiazepines (Xanax, Klonopin) or stimulants (Adderall, Ritalin) at the first few visits. *

I have read and understand policies regarding a new ADHD diagnosis and controlled substances