New Patient Form

Please print this page and complete as much as you can before your first appointment. If you wish to use insurance, you should contact your insurer to ask them the following questions. It is important you do this before the first visit, for some insurers will not cover your visit unless you have an authorization number first.
- What are my out-of-network mental health benefits?
- Do I need pre-authorization? If so, how do I get it?
- How many mental health visits per year am I approved for?

NAME (LAST, FIRST)

M.I.

BIRTH DATE

SOCIAL SECURITY NUMBER

STREET ADDRESS

CITY

STATE / ZIP

HOME PHONE

WORK PHONE

CELL PHONE

Circle which phone you prefer I call first.
If needed, may I leave a discrete message on your answering machine?-------Yes-------No

Would you like to receive your bill via email? -------Yes-------No

.......................................................................................................Email address:

In case of an emergency, is there someone I can contact? If Yes, list below:

NAME

PHONE

RELATIONSHIP

Insurance Information

This is for my records only. You are responsible for submitting your claims to the insurance company.

NAME OF POLICY HOLDER

POLICY HOLDER'S ID #

EMPLOYER'S NAME

INSURANCE PLAN NAME

POLICY GROUP OR FECA #

IS THIS YOUR ONLY PLAN?

Enter the policy holder's information, including birth date:

ADDRESS

CITY

STATE / ZIP

PHONE

BIRTH DATE, GENDER

RELATIONSHIP TO YOU

Agreement to Treatment

There are a few policies for you to know before beginning treatment:

1)    Confidentiality: This is described in the Privacy Policy.

2)    Availability: I am available by phone for emergencies by dialing my regular office number and following the emergency instructions. If I am away, I will designate another physician to be available.

3)    Payment: Payment is due at the time of your visit and can be made by check (to Valentine Raiteri, MD) or cash.

4)    Appointments: The time scheduled for your appointments is set aside exclusively for you, so it is important that you be on time to make use of it. Your first appointment will be 45 minutes long; subsequent appointments are usually scheduled for 30 or 45 minutes.

5)    Cancellations, Missed Appointments: If for any reason you can not make your scheduled appointment, please notify me as soon as possible. If I am unable to fill your appointment time or we are unable to reschedule for another time that same business week, you will be responsible for the full fee of your session. Since insurance does not reimburse for missed sessions, this fee will include the amount usually reimbursed by insurance.

You should feel free to discuss any aspects of these when we meet. In signing below, you agree to begin treatment with the policies above and acknowledge receipt of the Privacy Policy.

___________________________

Signature of Patient

_________

Date

Medication Information

What is your primary care physician's name and phone number?

When was your last physical?

Do you have any allergies to medications? ----Yes----No----Which ones?

What medical problems do you have?

What surgeries have you had?

Are you currently taking birth control? .........Yes.........No

Are you currently pregnant, breast-feeding or considering pregnancy? ----Yes ----No ----N/A

Below, please list all of the medications you are currently taking, including over-the-counter, vitamins, herbs, etc. Also list any psychiatric medications you have taken in the past.

(If you aren't sure what the medication is, try this link for help identifying pills)

NAME

DOSE

WHEN DID YOU START / STOP IT?

Other Places of Treatment

List the name and contact information for any therapists or doctors you currently see for treatment, as well as any psychiatrists, therapists or hospitals where you have previously received psychiatric care. If you plan on having your records released, click here for a form you can send past providers or call them to request your records be transferred.

NAME & TYPE OF TREATMENT

ADDRESS

PHONE

FAX