Patient Forms

We will give you the support and guidance you need to get started on the road of long-term recovery.

"*" indicates required fields

Which Location?*

How can we help?*

General Inquiry Form

Name

First Last

Email:

Phone:

Subject:

Message:

Psychiatry | Medication Management Inquiry Form

Name

First Last

Date Of Birth:

Phone:

Email:

Address

Street Address City State ZIP Code

Do you have Insurance?

Yes

Primary Insurance:

Primary Insurance ID:*

Do you have Secondary Insurance?

Yes

Secondary Insurance:

Secondary Insurance ID:*

What medications are you currently prescribed:*

Do you currently have any of the following providers?

A Primary Care Doctor?

Yes

A Psychiatrist?

Yes

A Therapist?

Yes

Primary Care Doctor (Full Name):

Doctor Phone Number:

If Yes and seeking therapy services with Bishop Health, why are you leaving your current provider?

Current Psychiatrist (Full Name):

Psychiatrist Phone Number:

If Yes and seeking psychiatry services with Bishop Health, why are you leaving your current provider?

Therapist (Full Name):

Therapist Phone Number:

How did you hear about us?

Individual Therapy Inquiry

Name

First Last

Date Of Birth:

Phone:

Email:

Do you have Insurance?

Yes

Primary Insurance:

Primary Insurance ID:*

Do you have Secondary Insurance?

Yes

Secondary Insurance:

Secondary Insurance ID:*

Do you have a therapist?

Yes

If Yes and seeking therapy services with Bishop Health, why are you leaving your current provider?

What medications are you currently prescribed:*

How did you hear about us?

TMS Registration Form

Name

First Last

Date Of Birth:

Phone:

Email:

Address

Street Address City State ZIP Code

Do you have Insurance?

Yes

Primary Insurance:

Primary Insurance ID:*

Do you have Secondary Insurance?

Yes

Secondary Insurance:

Secondary Insurance ID:*

Do you currently have any of the following providers?

A Primary Care Doctor?

Yes

A Psychiatrist?

Yes

A Therapist?

Yes

Primary Care Doctor (Full Name):

Doctor Phone Number:

Current Psychiatrist (Full Name):

Psychiatrist Phone Number:

Therapist (Full Name):

Therapist Phone Number:

Do you have any metal in your head, next or face area? (i.e. a steel plate in your skull)*

Yes

Question Answer: Do you have any metal in your head, next or face area? (i.e. a steel plate in your skull)

Do you have a history of seizures or a seizure disorder?*

Yes

Question Answer: Do you have a history of seizures or a seizure disorder?

Do you have any implants such as a vagus nerve stimulator or a pace make?*

Yes

Question Answer: Do you have any implants such as a vagus nerve stimulator or a pace make?

Is there any chance that you're currently pregnant?*

Yes

Question Answer: Is there any chance that you're currently pregnant?

Are you currently or have you ever been diagnosed with Bipolar Disorder?*

Yes

Question Answer: Are you currently or have you ever been diagnosed with Bipolar Disorder?

Are you currently of have you ever experienced psychotic symptoms such as hallucinations or paranoia?*

Yes

Question Answer: Are you currently of have you ever experienced psychotic symptoms such as hallucinations or paranoia?

Do you have a history of severe head trauma, dementia or tumors in the Central Nervous System (brain)?*

Yes

Question Answer: Do you have a history of severe head trauma, dementia or tumors in the Central Nervous System (brain)?

Do you currently have any issues with substance abuse/addiction?*

Yes

Question Answer: Do you currently have any issues with substance abuse/addiction?

Please list your current medication:

1. Name:

Dose:

Approximate State Date:

2. Name:

Dose:

Approximate State Date:

3. Name:

Dose:

Approximate State Date:

4. Name:

Dose:

Approximate State Date:

Please check the medications below that you've tried in the past:

Drug Choice 1

Drug Choice 2

Drug Choice 3

Please list any other medications not mentioned above:

How did you hear about us?

Ketamine Spravato Inquiry Form

Name

First Last

Date Of Birth:

Phone:

Email:

Address

Street Address City State / Province / Region ZIP / Postal Code

Do you have Insurance?

Yes

Primary Insurance:

Primary Insurance ID:*

Do you have Secondary Insurance?

Yes

Secondary Insurance ID:

Secondary Insurance ID:*

Do you currently have any of the following providers?

A Primary Care Doctor?

Yes

A Psychiatrist?

Yes

A Therapist?

Yes

Primary Care Doctor (Full Name):

Doctor Phone Number:

Current Psychiatrist (Full Name):

Psychiatrist Phone Number:

Therapist (Full Name):

Therapist Phone Number:

Do you have a history Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial and peripheral arterial vessels) or arteriovenous malformation?*

Yes

Question Answer: Do you have a history Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial and peripheral arterial vessels) or arteriovenous malformation?

Do you have a history of intracerebral hemorrhage?*

Yes

Question Answer: Do you have a history of intracerebral hemorrhage?

Do you have hypersensitivity to esketamine, ketamine, or any of the excipients?*

Yes

Question Answer: Do you have hypersensitivity to esketamine, ketamine, or any of the excipients?

Do you currently have any issues with substance abuse/addiction?*

Yes

Question Answer: Do you currently have any issues with substance abuse/addiction?

Are you currently on any medications?*

Yes

Please list your current medication:

Current Medications

Please check the medications below that you've tried in the past:

Drug Choice 1

Drug Choice 2

Drug Choice 3

Please list any other medications not mentioned above:

How did you hear about us?

Ketamine Infusion Inquiry Form

Name:

First Last

Date Of Birth:

Phone:

Email:

Address:

Street Address City State / Province / Region ZIP / Postal Code

Do you have Insurance?

Yes

Primary Insurance:

Primary Insurance ID:*

Do you have Secondary Insurance?

Yes

Secondary Insurance:

Secondary Insurance ID:*

Do you currently have any of the following providers?

A Primary Care Doctor?

Yes

A Psychiatrist?

Yes

A Therapist?

Yes

Primary Care Doctor (Full Name):

Doctor Phone Number:

Current Psychiatrist (Full Name):

Psychiatrist Phone Number:

Therapist (Full Name):

Therapist Phone Number:

Do you have a history of substance abuse (Alcohol, cannabis, non-prescribed medications, etc.)*

Yes

Question Answer: Do you have a history of substance abuse (Alcohol, cannabis, non-prescribed medications, etc.)*

Do you have a history of history of psychosis?*

Yes

Question Answer: Do you have a history of history of psychosis?*

Do you have a history of increased intracranial pressure?*

Yes

Question Answer: Do you have a history of history of psychosis?*

Are you currently pregnant?*

Yes

Do you have a history of uncontrolled hypertension?*

Yes

Question Answer: Do you have a history of uncontrolled hypertension?*

Do you have a history of Acute or unstable cardiovascular disease?*

Yes

Question Answer: Do you have a history of Acute or unstable cardiovascular disease?*

Have you had any previous negative response to ketamine?*

Yes

Question Answer: Have you had any previous negative response to ketamine?*

Are you currently on any medications?*

Yes

Please list your current medication:

Current Medications*

Please check the medications below that you've tried in the past:

Drug Choice 1

Drug Choice 2

Drug Choice 3

Please list any other medications not mentioned above:

How did you hear about us?

Which Medical Provider/Hospital?

Other - Please explain:

IOP External Referral Form

Thank you for referring your patient to Bishop Health IOP. Hours are Monday through Thursday 9a.m.-12p.m.and1:00p.m.-4:00 p.m. Our program treats adults with general behavioral health concerns. Program content includes psychiatric assessment, CBT and DBT grouptherapies andindividualtherapy.

If you have questions, please contact us at: (207) 910-6580

Date of Referral:

Demographic Information

Name of Patient:

Pronouns:

Address

Street Address City State / Province / Region ZIP / Postal Code

Best Contact #:

DOB:

Insurance Information

Insurance Co:

ID#:

Group #:

Subscriber Name:

DOB:

# To Verify Benefits:

Referral Source

Referring Provider Name:

Credentials:

Agency:

Phone:

Email (required):

Length of Treatment Relationship:

Date of most recent visit:

Clinical Information

Provide a brief description of the patient's current symptoms, functional impairment and reason why needs are best met at IOP level of care:

Provide a description of recent safety concerns including non-suicidal self-injurious behaviors, suicide behaviors or attempts, risk taking behaviors, inability to care for self and aggression or threats to others:

Clinical Goals

Primary Goal:

Secondary Goal:

Current Behavioral Health Diagnoses

Has the patient agreed to participate in Bishop Health IOP if accepted?

Yes

Is substance use an active concern?

Yes

Is an eating disorder an active concern?

Yes

What treatment alternatives to IOP have been or are being considered?

Yes

Previous Mental Health Treatment Programs (include hospitalizations, PHP/IOP, outpatient and substance use treatments):

Substance Use (current and history of problematic use)

Alcohol:

Tobacco:

Drugs:

Caffeine:

Current Medication (name, dose and frequency):

Medication allergies and adverse reactions:

Is the patient compliant with medications?

Yes

If not, what are identified barriers?

What medication adjustments or changes are deemed necessary?

Past Medical History

Any other pertinent social or trauma information

Current Outpatient Treatment

Psychiatrist:

Dietician:

Therapist:

Other:

Primary Care:

Anticipated prescriber at discharge:

*If the patient does not have a current outpatient prescriber, please list all referrals made for this patient, including status

Comments/Other Relevant Information

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