Intake form - Crestpoint Psychiatric Care

First Name*

Last name*

Date of Birth*

Email*

Cell Phone Number*

Home Address (Street)*

Home Address (City)*

Home Address (State, Zip Code)*

Insurance Carrier (PRIMARY INSURANCE)*

Member ID*

Who is the person listed as the primary insured?

Self
Spouse
Parent

Full Name and Date of Birth of the primary insured. If this is you, type "self".*

Attach a copy of your insurance card(FRONT)*

Attach a copy of your insurance card(BACK)*

IF APPLICABLE, attach here a COPY of Power of Attorney/Conservatorship letter.

Do you have more than one health insurance carrier?

YES
NO

Is this appointment for Intranasal ESKETAMINE used in the treatment of depression?

YES
NO
Would like to know more

Is this appointment for TMS Transcranial Magnetic Stimulation used in treatment of depression and anxiety?

YES
NO
Would like to know more

Is this visit a request for Psychiatric Consultation/Medication review ONLY?

YES
NO

We will need your Primary Care Doctor to fax a referral to our office. Fax # 423-631-0047

Policy Noted

In a few words, briefly state your reason for this appointment.*

List your ALL your current Psychiatric Medications. If none, type "NONE"*

PLEASE NOTE: Dr. Aimua DOES NOT conduct disability assessments and WILL NOT complete disability paperwork. Dr. Aimua DOES NOT conduct evaluation for Autism Spectrum

Policy Noted

TMS treatment requires you to come into the office daily (5 days a week for 6 weeks). Can you commit to this?

YES
NO
N/A

Intranasal ketamine treatment requires that you MUST have a designated driver who will pick up you from the office after your treatment as you are NOT allowed to drive for 24 hours after each treatment session. Do you have someone that you can designate as YOUR DRIVER?

YES
NO
N/A

Do you have any metal implants (brain clips, brain stent, shrapnel, bullet fragments) in the brain/head or neck area?

YES
NO
N/A

Have you ever had a brain bleed or any blood vessel/bleeding problems?

YES
NO

Do you have a history of epilepsy or seizures?

YES
NO

Name of your Primary Care Doctor and Office Phone Number. If you do not have one, type "None".*

Name of your Therapist OR Counselor and Phone Number. If you do not have one, type "None".*

Scroll down and read through “APPT F.A.Q” section.

Noted