Person filling out this form
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Person receiving care
Parent/Guardian of person receiving care (under 18 yrs)
Caretaker of person receiving care
Name
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Full name of person receiving care
First Name
Last Name
Middle Initial or Name
Preferred Name or Nickname
Date of Birth
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MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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If possible, please provide a phone number that can receive text messages as Dr. Jones will directly communicate via secure text.
(###)
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Secondary Phone
(###)
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Consent to direct communication from Dr. Jones via secure text
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e.g., Rx request status, office closure updates, etc.
Gender Identity
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Self-Describe Gender Identity
Pronouns
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Choose all that apply
Self-Describe Pronouns
Race
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Black/ African American
Asian
Hispanic/ Latino
Multiracial
American Indian/ Alaska Native
Hawaiian Native/ Pacific Islander
White/ Caucasian
Undefined
Other
Emergency Contact: Name, Phone #, & relationship to you.
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Name of your current Therapist/ Psychologist.
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Name & Contact # of your current Primary Care Provider
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Inpatient (Hospital-Based) or Residential Treatment:
LOCATION(S), DATE(S) & LENGTH(S) OF TREATMENT, REASON(S) FOR HOSPITALIZATION, WAS/WERE AFTERCARE PLAN(S) FOLLOWED? YES or NO
Notate multiple instances if applicable.
Outpatient Treatment: Individual Psychotherapy
PROVIDER NAME, IS TREATMENT CURRENTLY ONGOING? YES or NO, DURATION
Notate multiple instances if applicable.
Outpatient Treatment: Group or Family Psychotherapy
PROVIDER NAME, IS TREATMENT CURRENTLY ONGOING? YES or NO, DURATION
Notate multiple instances if applicable.
Outpatient Treatment: Partial Hospital or Intensive Outpatient Program
PROVIDER NAME, IS TREATMENT CURRENTLY ONGOING? YES or NO, DURATION
Notate multiple instances if applicable.
If you have previously taken medications for emotional/behavioral health, please provide the requested information for each medication:
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Please summarize use of tobacco, alcohol, and other substances (e.g. bath salts, cocaine, "ecstasy", heroin, LSD, marijuana, methanphetamine, PCP, peyote, psilocybin or "mushrooms".
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Include use of steroids, inhalants (e.g., glue, markers, spray paint, cleaning fluids), and cold medicines (other than for indicated use).
Please choose any/all previous or current issues.
Choose all that apply.
Other- please specify
Allergies to Medication/Food- please specify
Surgical History
NAME OF PROCEDURE(S), DATE(S) (MM/YYYY), REASON(S) FOR PROCEDURE(S)
Notate multiple instances if applicable.
Age of first menstrual period
Month and year of your most recent menstrual period:
Approximate date is fine.
MM
DD
YYYY
Are your menstrual periods regular?
Yes
No
Number of pregnancies:
Number of births:
Do you intend to become pregnant within the next two years?
Yes
No
I'm not sure
Sexual Orientation
Have you been sexually active within the last 6 months?
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Yes
No
No previous sexual activity
Do you (or your sexual partner(s)) use contraception and/or barrier protection?
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Yes
No
Please specify the type of birth control you use.
Who lived in the house with you when you were a child?
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Check all that apply
Number of sibilings:
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Were your parents married?
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Yes
No
Are any of the above persons deceased?
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Yes
No
Any additional information regarding the questions posed so far in this section:
Who lives in your current household? Please provide the NAMES & AGES for the members of your current household listed below:
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The next few following questions are required. Write N/A if non-applicable.
Support System: Please list those persons that you "lean on" or talk to for support:
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Please list their NAME(S) & RELATIONSHIP(S) to you. (List as many you'd like)
Education History: Please provide the LOCATION, GRADUATION STATUS, & DIPLOMA/DEGREE TYPE for the levels of education listed below.
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The next few following questions are required. Write N/A if non-applicable.
Employment Details: Please answer the following questions in regards to your current employment (Feel free to notate multiple jobs if applicable)
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The next few following questions are required. Write N/A if non-applicable.
Are you currently employed?
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Yes
No
Length of employment
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Job Title
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Work hours
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Do you work on weekends?
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Yes
No
Sometimes
N/A
Community Resources: Please provide the names of any /all community groups you are involved in.
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House of Worship:
Legal History: Please provide if you have a history of any of the following legal situations.
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Have you ever been arrested?
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Yes
No
Have you ever been on probation or parole?
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Yes
No
If YES, Completed or Not Completed?
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Completed
Not Completed
N/A
Please summarize family history of medical issues, behavioral health issues, and substance use below.
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FAMILY MEDICAL HISTORY (e.g., diabetes, kidney disease, heart disease)
RELATIVE(S), MEDICAL ISSUE(S), & any COMMENTS.
Notate multiple relatives/instances if applicable.
FAMILY BEHAVIORAL HEALTH HISTORY (e.g., anxiety, bipolar illness, depression)
RELATIVE(S), BEHAVIORAL HEALTH ISSUE(S), & TREATMENT(S) RECEIVED.
Notate multiple relatives/instances if applicable.
SUBSTANCE ABUSE/ MISUSE (e.g., alcoholism, substance abuse/dependence)
RELATIVE(S), SUBSTANCE(S), & TREATMENT(S) RECEIVED.
Notate multiple relatives/instances if applicable.
SYMPTOMS: Read the following symptom descriptions and choose those that apply to you.
How would you describe your leg sensations?
Choose all that apply.
How often do you experience these symptoms each month?
Please read through the following situations and choose those that apply to you within the past 30 days.
Choose all that apply.
Has there ever been a period of time when you were not your usual self and...
Choose all that apply
If you checked off MORE THAN ONE of the above, have several of these ever happened during the same period of time?
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Yes
No
N/A
Have you experienced any suicidal thoughts or ideations in the past 48 hours?
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Yes
No
Is there anything specific you would like to focus on with Dr. Jones? (+ any additional information)
Use this space to pinpoint areas you would like to address with Dr. Jones and share any extra information that you would like Dr. Jones to know prior to beginning care.
I hereby authorize the psychiatric team through PsychPhilly (Tracey Jones, M.D., P.C.) to provide psychiatric care, which may include evaluation, psychotherapy and/or medication management. I understand that this treatment may include both face to face and remote meetings and may require psychiatric and medical records as needed.
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I understand all fees for services rendered will be charged and handled solely through Cheyney University.
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I understand that I may be responsible for payment of fees assessed for preparation of letters, forms, and reports, (minimum cost of $15.00). Payment is due upon receipt of invoice. The base fee may increase based on the complexity level of the paperwork.
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I understand that if more than 90 days pass between appointments, then my chart is subject to deactivation. In this case, it is my responsibility to find another healthcare provider to continue treatment.
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OFFICE HOURS: Our office is open Monday-Friday from 9:00AM-5:00PM. Appointment hours vary by provider. Please contact your provider for specific availability hours.
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CONFIDENTIALITY AND PRIVACY: Patient confidentiality will be respected at all levels of communication and is protected by Federal and State laws. There are, however, situations in which confidentiality may be compromised and the provider’s professional and legal duty to protect may override the dictates of confidentiality. Briefly, the situations may include a strong indication of imminent danger to self or others or indication of abuse or neglect of another. Patients under the age of 18 require a parent or legal guardian’s signature to receive services. Please discuss your concerns about the limits of confidentiality with your provider and read the privacy statement provided.
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RELEASE OF INFORMATION: Following the execution of a valid Release of Information, patient records or a treatment summary will be forwarded to a licensed professional. Requests to obtain a personal copy of your medical chart and request to release records to any other entity (including attorneys) will be reviewed on an individual basis. This service is billed at the actual cost of supplying the records, and includes the cost of copying, mailing (when applicable), and professional time. Any request for release of records must allow at least two weeks’ preparation time.
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PRESCRIPTIONS, REFILLS, & PRIOR AUTHORIZATIONS: Prescription refill requests are made via our Rx refill request form found on the Rx Requests page of our website: www.psychphilly.com/rx-requests. Refill requests will be processed within two business days of receipt. For refills to be complete, the following information is needed: your name, name(s) and dose(s) of medication(s), & name and phone number of your pharmacy. Without this required information, your refill request will not be processed. Please do not make repeat Rx refill requests. If your pharmacy informs you that your refill has not been processed after 2 business days, please contact the office at frontdesk@psychphilly.com. Prescription refill requests will only be processed if you are currently under Dr. Jones' care. Prescriptions are typically given refills to cover you until your next appointment. If your appointment is rescheduled, complete a prescription refill request to prevent running out of your prescription(s).
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This notice describes how your medical information may be used and disclosed and how you can get access to this information. Please review it carefully.
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USES & DISCLOSURES OF HEALTH INFORMATION: With your consent, we will use and disclose your health information for treatment, including coordination of care, to obtain payment for treatment and for healthcare operations including evaluating the quality of the care you received.For other purposes, we will request that you sign an authorization to permit use and disclosure of protected health information. If you choose to sign an authorization to use or disclose information, you can later revoke that authorization to stop any further uses and disclosures. We may disclose identifiable health information about you without your consent or authorization for several other reasons. Subject to certain requirements, we may give out health information without your consent or authorization for public health purposes, auditing purposes, research studies, and emergencies. We will also provide information when otherwise required by law, such as for law enforcement in specific circumstances. We may contact you to provide information about appointments, treatment alternatives or health benefits or services that may be of interest to you. We may contact you regarding payment information. We may disclose certain information to the plan sponsor of your group health plan. We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and give or send you a copy. You can also request a copy of our notice at any time. For more information about our privacy practices contact the party listed below.
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INDIVIDUAL RIGHTS: In most cases, you have the right to look at or get a copy of health information about you that we used to make decisions about you. However, pursuant to the Pennsylvania Mental Health Procedures Act we may deny you access to certain information or to types of information in your file. If you request copies, we will charge you in accordance with current state laws pertaining to this issue. You also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment, operations or related administrative purposes. If you believe that your record is missing, you have the right to request that we correct the existing information or add the missing information. You may request in writing that we do not use or disclosure information for treatment, payment and operations except where specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally required to accept it.
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COMPLAINTS: If you are concerned that we have violated your privacy rights, or if you disagree with the decision we made about access to your records, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The party listed below can provide you with the appropriate address upon request.
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OUR LEGAL DUTY: We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice. If you have questions or complaints, please contact our office directly.
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Direct contact information:
Tracey Jones, M.D., P.C.
1511 Carpenter Street
Philadelphia, PA 19146
Phone: 215-923-2690
Fax: 215-923-8940
Email: frontdesk@psychphilly.com
Digital Signature - Name of person receiving care
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By typing my name below, I hereby grant the use of this information for the reasons explained in this form.
First Name
Last Name
Digital Signature - Parent/Guardian or Caretaker
Please utitilze this field if you are filling this out on behalf of somebody else. (Please place the patient's name in the field above.) By typing my name below, I hereby grant the use of this information for the reasons explained in this form.
First Name
Last Name
Today's Date
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MM
DD
YYYY
