Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Gender
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Address
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Email
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Phone Number
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(###)
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May we leave voicemails at or send texts to this number?
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Primary Pharmacy (Address & Phone Number)
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Who is responsible for the bill?
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Name
Primary Phone Number
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Relationship to Patient
Name
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Address
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Relationship to Patient
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Primary Phone Number
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(###)
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Name
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Address
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Phone
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(###)
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Therapist Name & Phone Number
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 wiII 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.
PLEASE REFER TO THE FUNCTIONAL PSYCHIATRY EVALUATION PAGE FOR FEES.
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 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. 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
Credit cards can be processed in the office at the time services are rendered. However, if you have an outstanding balance at the end of the billing cycle, your credit card will be automatically billed. Your information will be kept on file, and your are responsible for updating the office with any changes to your billing.
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.
Cardholder Name
Credit Card Number
Phone Number
(###)
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Expiration Date
Security Code
Zip Code
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 (48 hours for new patient appointments). 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.
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Today's Date
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MM
DD
YYYY
What is your current reason for seeking treatment?
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Have you ever been diagnosed with a mental health issue?
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Name of Current or Past Psychiatrist
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Approximate Date of Last Visit
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Current Medications
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Please include all prescribed or over-the-counter medications and list dosage, approximate date of use and any side effects, if known.
Vitamins & Supplements
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Please list dosage, approximate date of use and any side effects, if known.
Past Psychiatric Medication
Please list any psychoactive mediations tried (prescription or non-prescription), dosage, approximate date of use and any side effects, if known.
Have you ever had a psychiatric hospitalization? Was it inpatient or at a day hospital?
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If yes, what year was it, and what was the diagnosis?
Have you ever attempted to take your own life?
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If yes, when, how and under what circumstances?
Have you ever self-harmed (e.g. cutting or burning)?
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If yes, when, how and under what circumstances?
Do you have a history of trauma?
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If so, please elaborate.
Have you ever drank more heavily than you do now?
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Have you ever taken unprescribed drugs?
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This includes "street" drugs or medications that were prescribed for another person.
Have you ever been treated for a substance abuse disorder?
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Do you have family history of the following?
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Check all that apply.
Is there any other family psychiatric history?
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Have you suffered from any of the following:
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Check all that apply.
Current Weight
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Weight One Year Ago
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Any hospitalizations or surgeries?
Please list types of surgery, dates and lengths of stays.
Are you having periods?
Date of Last Menstrual Period
MM
DD
YYYY
Menses
Do you have any premenstrual symptoms?
If so, on which day of your cycle?
Possibility of current pregnancy?
Any past pregnancies, miscarriages, abortions or complications?
Has there been a recent change in your sexual functioning?
Are you postmenopausal?
If so, at what age did you enter menopause?
Have you had your hormone levels checked?
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If so, please provide copies of your results.
Has there been a recent change in your sexual functioning?
Has any member of your family experienced any of the following?
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Check all that apply.
Please elaborate.
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Include which family members experienced any of the above, as well as and additional relevant medical history.
Breakfast
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Lunch
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Dinner
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Snacks
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How much fluids would you estimate you drink a day? How much caffeine?
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Do you follow a vegetarian, vegan, or pescetarian diet?
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Do you incorporate fermented foods into your diet? If so, what type?
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Do you eat dairy? Gluten? Sugar? Artificial Sweeteners? If so, which type?
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Overall, how would you characterize the quality of your nutrition?
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Do you buy organic produce?
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Do you practice intermittent fasting? If so, during which hours?
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How many hours before bedtime do you stop eating?
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Do you supplement your diet with protein?
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If so, what type and how many grams per day?
Do you take any other dietary supplements?
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Do you have any food sensitivities or allergies?
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Have you ever been tested for food allergies or sensitivities?
Have you ever worked with a nutritionist or dietitian before?
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Have you ever been tested for Celiac Disease?
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Do you frequently use antibiotics?
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Have you ever seen a functional medicine provider before?
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If so, whom, when, and for what reason? If you have previous testing from a functional provider, please provide copies.
Do you consume alcohol?
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If so, how much and how often? Have you ever drank more in the past than you do currently?
Do you smoke?
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If so, what do you smoke? Nicotine? Marijuana? Vapes or e-cigarettes? Have you ever smoked more than you do currently?
Please elaborate on any other substance use.
Describe your sleep habits.
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How many hours of sleep do you typically get per night? Do you have difficulty falling or staying asleep? Do you suffer from daytime drowsiness? Have you ever had a sleep study or been diagnosed with sleep apnea?
Describe your stress levels.
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Low? Moderate? Severe? Do you have acute stressors? Chronic stressors?
Describe your exercise habits.
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Describe your mindfulness practices.
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Yoga? Meditation? Is spirituality/religion important to you?
Describe any potential toxic exposures.
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Do you use plastic water bottles? Do you drink filtered water? Have you had a mold exposure? Do you use environmentally-friendly cleaning products?
Is there anything else that Dr. Shosid should know?
