Patient Forms

Patient Registration Form

Are You Registering an Adult or Child?(Required)

Adult

Child

Patient Information

Name(Required)

First Middle Last

Email(Required)

Birth Date(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone(Required)

Mobile Phone

Employer(Required)

Work Phone(Required)

Martial Status(Required)

Gender(Required)

Primary Physician(Required)

Primary Physician Phone(Required)

Primary Physician Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Source of Referral(Required)

Parent/Guardian/Emergency Contact Information

Mother Name(Required)

First Last

Mother Employer(Required)

Mother Occupation(Required)

Mother Home Phone(Required)

Mother Mobile Phone

Mother Address (if different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Father Name(Required)

First Last

Father Home Phone(Required)

Father Mobile Phone

Father Employer(Required)

Father Occupation(Required)

Father Address (if different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact

Emergency Contact Name(Required)

First Last

Emergency Contact Home Phone(Required)

Emergency Contact Mobile Phone

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(If different from patient)

Insurance Information

Policy Holder Name(Required)

First Last

Policy Holder Birth Date

Relationship to Patient(Required)

Insurance Company Name(Required)

Insurance Company Phone(Required)

EID/Payer ID(Required)

Policy Holder ID Number(Required)

Group Number(Required)

Claims Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Consent to Treat(Required)

I agree to the treatment policy.

I hereby authorize Axon Health Associates, LLC and its respective personnel to provide evaluation and treatment. I understand that these services are not guaranteed as to results, that no guarantees have been provided by Axon Health Associates, LLC, and that there are certain risks involved with these services. I understand that I can terminate this consent for treatment by requesting termination in writing.

Privacy Acknowledgement(Required)

I agree to the privacy policy.

I understand that the patient’s health information is private and confidential. I understand that with this consent, I give permission for aspects of my/my child's private healthcare information to be shared with Axon Health Associates, LLC, as is necessary for services to be provided. I understand that Axon Health Associates, LLC may use and disclose the patient’s personal health information to help provide care to the patient, to handle billing and payment, and to take care of other health care operations. In general, there will be no other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this information without my permission. By law, Axon Health Associates, LLC must report actual or suspected child or elder abuse to the appropriate authorities. In addition, Axon Health Associates, LLC is legally bound to take appropriate action if my child or I threaten anyone with violence, harm, or dangerous actions. I understand that there is a detailed document titled “Notice of Privacy Practices” that contains more information about the policies and practices protecting my privacy. I understand that I have the right to read the “Notice” before signing this acknowledgment. I am aware that a copy of this notice will be given to me upon my request or that it may be found at axonhealth.org. Axon Health Associates, LLC has established procedures which help meet patient obligations. These procedures may include other signature requirements, written acknowledgments, and authorizations; reasonable time frames for requesting information; charges for copies and non-routine information needs, etc. I will assist Axon Health Associates, LLC by following these procedures if I choose to exercise any of my rights described in the “Notice of Privacy Practices”. My signature below indicates that I have been given the chance to review a current copy of the “Notice of Privacy Practices”.

Financial Agreement(Required)

I agree to the financial agreement.

I agree to pay in full, at the time of service, for all services rendered for myself or my child by Axon Health Associates, LLC, for any out-of-network services. I understand that there is a document available upon request or at axonhealth.org regarding the Fee Schedule and any financial obligations, and I have read and agree with the information in this document. For in-network services, I agree to pay for my copay at the time of service and understand that my insurance company will be billed for the remainder. I am aware that there is a document titled Insurance Tips that is available upon request or at axonhealth.org. This document will be helpful to understand what portion of the fees may be covered by my insurance plan. I understand that 24 hours notice of cancellation is required to avoid charges for missed appointments. I understand that in families where parents do not share the same household, payment for services is the responsibility of the parent who accompanies the child to the appointment.

I also understand and agree to pay for any services related to legal matters, including but not limited to depositions, attorney phone calls, and court testimony; these services may be a different pay rate.

I also understand and agree to pay for services including record retrieval, phone consultation, and email consultation as requested by the provider.

Consent to use Email Communications(Required)

I agree to the email policy.

I hereby agree to sending to and receiving from Axon Health Associates, LLC email communications as part of comprehensive treatment for my child. I understand the risks of sending PHI through email even with encryption, and with this agreement I am accepting these risks to my child's PHI. I accept that Axon Health Associates, LLC shall not be held responsible for any exposure of email communications at my home or place of employment, depending on the location of my email address. I also understand that email communications can fail in their transmission, and I agree to contact Axon Health Associates, LLC if I have not obtained a response from my email communication within three business days. I also agree to never use email communications for emergency situations, and to call the office directly with any emergencies. I understand that I can terminate this agreement at any time by informing in writing. With my signature, I believe that the benefits of using email communications for my child's healthcare outweigh the security risks.

Patient History Questionnaire

Patient Name(Required)

First Last

Birth Date(Required)

Person Completing Questionnaire(Required)

Relationship to Patient(Required)

Purpose of Evaluation

What Are Your Primary Questions and Concerns?

Past Medical History

Have you ever been diagnosed with a medical condition?(Required)

Yes

(please list)(Required)

Have you ever been Hospitalized?(Required)

Yes

When and for what condition?(Required)

Have you ever had surgery?(Required)

Yes

What was the surgery for?(Required)

Are you currently taking any medications?(Required)

Yes

List medication and dosage.(Required)

Current Medical Concerns

Do you have any allergies to medications?(Required)

Yes

List medication.(Required)

Do you have any sleep concerns?(Required)

Yes

Describe.(Required)

Do you have any concerns with energy level?(Required)

Yes

Describe.(Required)

Do you experience headaches?(Required)

Yes

With what frequency?(Required)

Do you experience stomach pain?(Required)

Yes

With what frequency?(Required)

Past Mental Health Treatment

Please list any previous medications that you have been prescribed for mood, anxiety, or attention and any side effects you experienced.(Required)

Have you ever received counseling or psychotherapy?(Required)

Yes

When and what was the name of the therapist?(Required)

Please list any prior mental health treatment programs, including substance abuse treatment, intensive outpatient or partial hospital programs, or psychiatric hospitalizations.(Required)

Educational History

Highest Level of Education Achieved(Required)

Some High School

High School Diploma

Some College

Associate's Degree

Bachelor's Degree

Additional Post-Secondary Education

Family History

Please list the persons presently living in your home.

Name

Gender

Birth Date

Relation to Patient

During the past 12 months has your family experienced Death of a Family Member?(Required)

Yes

During the past 12 months has your family experienced Marital Problems?(Required)

Yes

During the past 12 months has your family experienced Serious Illness?(Required)

Yes

During the past 12 months has your family experienced Unemployment?(Required)

Yes

Other(Required)

Yes

(please describe)(Required)

Have any family members experienced Depression?(Required)

Yes

Have any family members experienced Anxiety?(Required)

Yes

Have any family members experienced ADHD?(Required)

Yes

Have any family members experienced Autism?(Required)

Yes

Have any family members experienced Bipolar disorder?(Required)

Yes

Have any family members experienced Schizophrenia?(Required)

Yes

Have any family members experienced Other mental health diagnoses?(Required)

Yes

Have any family members experienced Heart or blood pressure problems?(Required)

Yes

Describe(Required)

Have any family members experienced Other medical problems?(Required)

Yes

Describe(Required)

Patient History Questionnaire

Child Name(Required)

First Last

Birth Date(Required)

Person Complete Questionnaire Name(Required)

First Last

Relationship to Patient(Required)

Purpose of Evaluation

What are your questions or concerns regaurding your child?(Required)

Pregnancy and Birth History

Is this your biological or adopted child?(Required)

Biological

Adopted

If adopted, at what age did you adopt this child?(Required)

Is the child aware of the adoption?(Required)

Yes

Did you have any health problems during your pregnancy with this child?(Required)

Yes

Please described nature of these complications such as infection, bed rest, high blood pressure(Required)

Did you take any medications or use any drugs, alcohol or tobacco during pregnancy?(Required)

Yes

Was your baby carried for a full nine months?(Required)

Yes

Please indicate the length of pregnancy(Required)

Did your baby need any special care after delivery?(Required)

How much did your baby weigh at birth?(Required)

Past Medical History

Has your child ever been hospitalized?(Required)

Yes

Please describe the reason and what age this occurred.(Required)

Has your child ever had any serious accidents or head injuries?(Required)

Yes

Please describe and include your child’s age.(Required)

Has your child had any serious or chronic illnesses (asthma, allergies, diabetes, etc)?(Required)

Yes

Please describe and state if it has resolved.(Required)

Has your child ever had a seizure?(Required)

Yes

Please state at what age.(Required)

Has your child ever had any tics (repetitive facial movements, throat clearing, sniffing, eye blinking, etc.)?(Required)

Yes

Is your child taking any medications?(Required)

Yes

Please list medication and dosage.(Required)

Does your child have any allergies to medications?(Required)

Yes

Please describe.(Required)

Do you have concerns about your child’s eating habits?(Required)

Yes

Please describe.(Required)

Do you have concerns about your child’s sleep?(Required)

Yes

Please describe.(Required)

Does your child complain of pain more than once a week (headaches, stomachaches)?(Required)

Yes

Developmental History

Did you have any concerns about your child’s development?(Required)

Yes

Please explain.(Required)

At what age did your child roll over?(Required)

At what age did your child sit alone?(Required)

At what age did your child crawl?(Required)

At what age did your child walk?(Required)

At what age did your child begin saying single words?(Required)

At what age did your child begin combining words?(Required)

Did your child have any developmental therapies (OT, PT, Speech)?(Required)

Yes

What age?(Required)

At what age did your child become toilet trained?(Required)

Does your child currently have any daytime accidents?(Required)

Yes

How often?(Required)

Does your child have any nighttime accidents?(Required)

Yes

How often?(Required)

Past Mental Health Treatment

Please list any previous medications that your child has been prescribed for mood, anxiety, attention or behavior and any side effects he/she may have experienced.(Required)

Has your child ever had any behavior therapy or counseling?(Required)

Yes

Please include your child’s age at the time and the name of the therapist.(Required)

Educational History

Please list the schools your child has attended:(Required)

School Name

Dates Attended

Please describe any educational services or resources that are provided to your child (IEP, 504 plan, special education services, etc.)(Required)

Please describe any extracurricular activities in which your child participates.(Required)

Please describe your child’s peer group and how he/she interacts with others.(Required)

Family History

Parents are(Required)

Date(Required)

Describe custody arrangement and visitation.(Required)

Please list the persons presently living in your home.(Required)

Name

Gender

Birth Date

Relation to Child

Present or Highest Grade Completed

Family members who no longer live in the home with the child.(Required)

Name

Gender

Birth Date

Relation to Child

Present or Highest Grade Completed

During the past 12 months has your family experienced(Required)

Death of a Family Member

Serious Illness

Marital Problems

Unemployment

Other

Please Describe.(Required)

Have any family members experienced Anxiety?(Required)

Yes