We are honored that you have chosen us to partner with in your treatment and are looking forward to meeting you.  
The forms below will provide information on your background and history so we can spend more of your first visit
focusing on your current struggles and concerns.

To complete your forms by hand:   Please print the
entire column of forms beneath the patient heading appropriate to your visit.  
Help us help you.  ALL forms
must be completed in BLACK ink so that they can be scanned into the Electronic Medical Record
(EMR).
Because colored ink does not scan, forms completed in colored ink will need to be redone.

Completed forms MUST be brought to the initial appointment if they are not submitted prior to the appointment.  
If we do not have the completed forms by the time of your visit, you will need to complete the forms when you arrive,
cutting into your appointment time.  This will require a second appointment to finish the evaluation process.  
The completed forms allow us to complete an evaluation in one visit and enable us to begin working with you
to implement your treatment plan immediately.  You may fax your completed forms to us
prior to your visit at 972-335-2434.  

If you prefer to complete your forms on your computer, simply download the entire column of forms beneath the patient heading
appropriate to your visit and save to your desktop.  You may then go to a site such as
www.fillanypdf.com where you can import
the blank pdf patient forms, complete them on your computer, and download the completed forms to save to your desktop.  
Then you can print them to fax them to us at 972-335-2434 or bring to your first appointment.  While it is possible to send your
completed pdf forms as an attachment, please note that we
DO NOT suggest that you e-mail forms as this is not a secure way
to transmit your personal information
.  If you choose to do so, please understand that it is at your own risk.
ADULT
(over 18)
Complete in black ink, please

Adult New Patient Forms

Medication History
ADOLESCENT
(13-18 y.o.)

Complete in black ink, please

Adolescent New Patient
Forms

Medication History

Vanderbilt Parental
Assessment

Vanderbilt Teacher
Assessment

The Vanderbilt
Assessments are separated
out so that they can be
reprinted for evaluating
progress at various
intervals
CHILD
(10 - 12 y.o.)

Complete in black ink, please

Child New Patient Forms

Medication History

Vanderbilt Parental
Assessment

Vanderbilt Teacher
Assessment

The Vanderbilt Assessments
are separated out so that
they can be reprinted for
evaluating progress at
various intervals
We are not Medicare
providers and patients
may
not submit for
reimbursement.
Therefore, those
eligible for Medicare
will also
need to complete this
Medicare Private
Contract
If you were referred by a medical professional,
download and complete the Release of Information
so that we can communicate with them.   Be sure to initial
all blanks, and to sign and date the form.

A separate form should be completed for
each previous
psychiatrist, counselor or inpatient or residential facility you
have had treatment from  so that we can request records.  Ideally
you will complete the request and fax it to these providers now
so that we can have the records prior to your appointment.
MARITAL or
COUPLE'S

Complete in black ink, please

Each partner needs to
complete the following
:

Marital History Form

Medical and Social
History

Medication History

Personality Profile

Adult ADHD
Self-Report

Mood Disorders Screen

Cage & Scoff Screens

Office Policy and Consent
for Treatment
Credit Card Authorization
We are not Medicare
providers and patients
may
not submit for
reimbursement.
Therefore, those
eligible for Medicare
will also
need to complete this
Medicare Private
Contract
Family

Each family member
should complete:

Personality Profile

An
adult family member
should complete the
following on behalf of the
family:

Family Questionnaire

Office Policy and Consent
If you have had previous
family therapy, it would
be useful to get your
previous records.  To
facilitate this,  have each
individual over
the age of 18 complete the
following (parents will
list children under the age
of 18 on parent's form):

Release of
Information
We are not Medicare
providers and patients
may
not submit for
reimbursement.
Therefore, those
eligible for Medicare
will also
need to complete this
Medicare Private
Contract
Need to pre-pay an appointment?

If you are pre-paying your appointment, or paying for someone else, you may do so in two ways.  

You may click on the Pay On Account button on the left of the screen to pay by credit card
or
Stop by our office and you may pay by cash, or credit card.  

If you are continuing to pay for ongoing appointments, you will need to  fax a completed
Credit Card Authorization (above in the green box), along with a copy of the card,
- front and back -
to our secure fax at 972-335-2434.   

A NOTE TO INDIVIDUALS WHO ARE FINANCING TREATMENT FOR SOMEONE ELSE:  
Pre-paid appointments have the same cancellation requirements as in our general office policy which can be reviewed in our
office policy and on the credit card form.  Pre-paid appointments for which the patient no shows or does not provide adequate
notice of cancellation
FOR ANY REASON will not be refunded as the time has been reserved specifically for that patient.  

By proceeding with prepaying an appointment, payer understands and agrees to abide by this policy.
Complete a release of information for each of your previous health care professionals and fax it to them so that we can
receive  records prior to your appointment.  They can be faxed to us a 972-335-2434.

Records Request
We are not Medicare
may
not submit for
reimbursement.
Therefore, those
eligible for Medicare
will also
need to complete this
Medicare Private
Contract
Stonebriar Psychiatric Services, P.A.
972-335-2430
3550 Parkwood Blvd.  Suite 705
Frisco, TX  75034