Patient Legal Name
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Date of Birth
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Gender
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Grade & School
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Patient Address
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Full Address, City, State & Zip Code
Patient Cell Phone Number
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Parent #1 Name, Address, Phone Number & Email
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Parent #2 Name, Address, Phone Number & Email
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Parents are:
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If divorce or separated, please include a description of the custody arrangement and the divorce decree regarding medical services.
Who is responsible for the bill?
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If someone else, please provide their name, address, phone number and e-mail address, and describe their relationship to the patient.
Name
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Relationship to Patient
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Primary Phone Number
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Primary Care Physician Name, Address & Phone Number
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Pharmacy Address & Phone Number
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Therapist Name & Phone Number
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Who referred you to our practice?
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Please read the below.
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Dr. Shosid is considered an out-of-network provider as she is not contracted with any insurance companies. 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. This form can be submitted through the website under the Documents and Forms section. 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 of file to hold the scheduled time slot. The credit card wi II 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 one-hour evaluation or consultation appointment is $650 for adult patients. The charge for the initial child and parent evaluation is $650 each and subsequent evaluation appointments will be charged at $600. The charge for an hour-and-a-half adolescent consultation appointment is $850. 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 $450. The charge for medication follow-up appointments ranges from $250 to $350 depending on allotted time. A $35 - $50 fee will be charged if the office is required to obtain a prior authorization for medication from your msurance company.
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. This form can be submitted through the website under the Documents and Forms section. After-hours or weekend calls for routine matters that are non-emergent, will be subject to charges accordingly. Appointments are made through office manager, Michelle Bell. All e-mails go through the office manager. The office does accept faxes at 972-490-3567.
Please allow 48 hours for processing of medication refills. All requests should be made via fax through your pharmacy. 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. Shosid is able to provide a three month supply of controlled substances, if permissible by your insurance.
Dr. Shosid is a HIPAA compliant healthcare provider. Please refer to Dr. Shosid's 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.
Credit Card Information
If you plan on using a credit card for payment please complete. Credit cards can be processed in the office at the time services are rendered. As this is not always possible we require a credit card be left on file. Please update the office with any changes to your billing information. We do accept HSA cards for your convenience.
Please note that existing patients must cancel 24 hours in advance of appointments to avoid a cancellation fee. New evaluations must cancel 48 hours in advance.
Card Holder Name
Credit Card Number
Expiration Date
Security Code
Zip Code
Phone Number
I hereby give my authorization and consent for the above card to be used for payment to Nancy Shosid, MD. The billing charge will reflect the service rendered per the office policy and will be itemized on the monthly billing statement. I understand that I am financially liable for fees incurred due to failure to cancel appointments 24 hours in advance. Please be aware that the date(s) listed on your credit card statement will reflect the date of processing the charge, not necessarily the actual date of service, since not all fees are processed on the date of service. *
Today's Date
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Patient Name
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I certify that I am the father, mother or legal guardian of the above named child and I hereby give my authorization and consent for the above named child to receive psychiatric outpatient diagnostic and treatment services.
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Briefly describe your reason for seeking treatment.
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Describe the patient's main symptoms.
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Please check any areas below which have worsened due to the patient's current problems.
Is the patient adopted? If so, please elaborate.
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Were there any complications with pregnancy, delivery, or during the postpartum period?
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Current Height & Weight
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Do you have any concerns about the patient's current eating habits? Are there any recent changes in the patient's height or weight?
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Describe the patient's current sleeping habits.
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How many hours of sleep does the patient get per night? Does the patient have difficulty falling asleep? Nighttime awakening? Nightmares? Sleep walking?
Describe the patient's exercise habits. Does the patient participate in any individual or team sports?
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Does the patient have any current or prior medical problems?
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Has the patient ever been hospitalized or undergone surgery?
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Does the patient have any known drug allergies or adverse reactions to medications?
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Has the patient experienced any of the following?
Has the patient experienced any other medical conditions not listed above?
Onset of Puberty:
Is the patient having periods?
Date of Last Menstrual Cycle
Menses is:
Onset of Puberty:
Has the patient fainted or passed out DURING exercise?
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Has the patient fainted or passed out AFTER exercise?
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Has the patient ever had extreme fatigue associated with exercise (different from other adolescents)?
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Has the patient ever had unusual or extreme shortness of breath during exercise?
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Has the patient ever had discomfort, pain or pressure in his or her chest during exercise?
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Has the patient ever been told he or she has a heart murmur?
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Are there any family members who died of heart problems before age 50?
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Are there any family members who had an unexpected, unexplained death before age 50?
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Please explain more about any "yes" answers.
Does the patient have a previous psychiatric or learning difference diagnosis?
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If so, when was the diagnosis made and by whom? Please elaborate.
Has the patient had previous psychoeducational testing or neurophysical testing?
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If so, please provide a copy to our office manager.
If so, when?
Has the patient ever been treated by a psychiatrist in the past? If so, please give type of treatment as well as start and end date.
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Has the patient ever had individual psychotherapy? If yes, when and with whom?
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Has the patient ever attended group/family therapy? If yes, when and with whom?
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Current Medications
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Include name of ALL medication, supplements, dosage, reason is was prescribed, who prescribed it and if there were any side effects.
Past Psychiatric Medications
Include name of ALL medication, dosage, reason it was prescribed, who prescribed it, when it was taken and if there were any side effects.
Does the patient have a history of trauma?
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When did the patient's symptoms begin? Did something occur to precipitate them?
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Have there been any symptom-free periods? If yes, when and for how long?
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Has the patient ever been psychiatrically hospitalized? If yes, when, how and under what circumstances?
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Has the patient attended Day Hospital or an Intensive Outpatient Program?
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Has the patient ever hurt him or herself in any way (e.g. cutting or burning)? If yes, when, how and under what circumstances?
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Has the patient ever thought of or attempted to commit suicide? If yes, when, how and under what circumstances?
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The patient experiences the following issues regularly:
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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
Please elaborate on the above.
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Describe the patient's activities, interests, hobbies, skills & strengths.
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Are there any concerns regarding the patient's social interactions with individual peers or in a group setting?
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Any concerns about grooming, self-care or hygeine?
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Describe the patient's living arrangement.
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Who is in the household? Include age of siblings. If the parents are divorced, please describe the visitation schedule.
Do the patient's parents work outside of the home?
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Please include all occupations and whether the jobs are full- or part-time.
Are there other adults who help provide care for the patient? If yes, please describe.
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List any events or stressors which, in your opinion, have important meaning to the patient.
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Did the patient experience significant delays with motor, language or social skills?
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Has or does the patient need special services?
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Speech Therapy, Occupational Therapy or Physical Therapy
Does the patient receive special accommodations or special education services or have a learning difference? Please describe.
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Describe the patient's grades. Any academic concerns?
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Has the patient ever had to repeat a grade?
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If yes, which one?
Describe the patient's relationship to teachers.
Describe the patient's relationship with his or her peers.
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Has the patient ever been involved in truancy or other legal proceedings?
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Has any family member had any of the following?
Please elaborate on the above as needed.
Please include which family members experienced the issues you selected.
Are there any significant MEDICAL issues on the FATHER's side?
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Are there any significant MEDICAL issues on the MOTHER'S side?
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Is any additional information Dr. Shosid should be aware of?
