Crescent Comprehensive Clinic PLLC
Psychiatric Services
www.crescentcomprehensive.com
CONFIDENTIAL ADULT PATIENT/FAMILY HISTORY
INSTRUCTIONS: Please briefly fill the form and bring the filled form to your first appointment.
PATIENT CONTACT / PAYMENT INFORMATION
Patient Name: ______
Referral Source: ______
Date of Birth: ______Sex: ______Marital Status: ______
Address: ______
Cell Phone: ______☐Preferred ☐ Text ☐ Voicemail
Home Phone: ______☐Preferred ☐ Text ☐ Voicemail
Work Phone: ______☐Preferred ☐ Text ☐ Voicemail
Email: ______
Preferred Method of Communication: ______
Spouse and contact: ______
PAYMENT INFORMATION
Patient Payment Preference: ______
Insurance Company Name: ______
Insurance Plan Type: ______
Insurance Group ID: ______
Insurance Individual ID: ______
Name of the Insured Person: ______
Date of birth of Insured: ______
Relationship of the Patient with Insured person: ______
PHARMACY INFORMATION
Name: ______Phone: ______Fax: ______
Address: ______
PRIMARY CARE PHYSICIAN INFORMATION
Name: ______
Address: ______
Phone: ______Fax: ______Date of Last Visit: ______
REASON FOR PSYCHIATRIC EVALUATION: ______
______
PSYCHIATRIC MEDICATION HISTORY:
Past Medications / Dosage / Reason / Prescribed By:Current Medications / Dosage / Reason / Prescribed By:
PSYCHIATRIC HISTORY:
Treatment / DetailsPsychiatrist
Psychotherapy
Diagnosis
Educational Testing
Psychological Testing
Psychiatric hospitalization
Self-Harm
Suicide
Homicide
Others
MEDICAL HISTORY:
Age / DescribeDrug Allergies
Asthma
Cancer
Diabetes
Epilepsy
Headaches
Heart Disease
Loss of Consciousness/Injury
Hospitalizations
Surgeries
Non-Psychiatric Medications
Other
STRESSES / TRAUMA: (move, marital, financial, job, abuse, legal, medical, family)
Past: ______
Current: ______
FAMILY PSYCHIATRIC HISTORY:
Diagnosis / Relative who is diagnosedAnxiety Disorder/OCD/PTSD
Depression
Bipolar mood Disorder
Autism
Intellectual Disability
Alcohol Abuse
Drug Abuse
Eating Disorders
ADHD/ ADD
Learning Disabilities
Physical Violence
Other
FAMILY MEDICAL HISTORY: ______
______
SOCIAL HISTORY:
Highest Education: ______
Current Job: ______Duration: ______
Living with: ______
Children: ______
Siblings: ______
Current relationship: ______
Legal issues: ______
Religious/spiritual practices: ______
WHAT ARE YOUR EXPECTATIONS FROM THIS TREATMENT? ______
______
SIGNATURE OF PERSON COMPLETING THE FORM / DATESIGNATURE OF PSYCHIATRIST / DATE
Crescent Comprehensive Clinic
Client Consent for Services
I,______, hereby give my full consent for myself/my child/teen, ______, DOB ______to receive services from Crescent Comprehensive Clinic until I notify Crescent Comprehensive Clinic of any changes or until Crescent Comprehensive Clinic determines that services are no longer necessary. If I am referring my child/teen for mental health services, I certify that I have legal responsibility for this child/teen, and I am authorized to seek treatment for him/her. I understand that Crescent Comprehensive Clinic may request the completion of questionnaires for treatment purposes, for specific research projects conducted within Crescent Comprehensive Clinic or for outcome studies. A member of the staff shall explain these questionnaires, and I have the right to choose not to participate in any research project. I understand that there is an expectation that I/we will benefit from the services provided, but there is no guarantee that this will occur. There is also no guarantee regarding the duration of treatment. I understand that my sessions may deal with sensitive and difficult topics, may elicit uncomfortable emotions and may lead to individual decisions that may be temporarily disruptive for me and my family. I understand that I will be informed if a clinical trainee will be present during my session. I also understand that all information disclosed within my sessions is confidential and will not be revealed to anyone outside the supervision team without written permission unless required by law or necessary to comply with the requirements of accrediting agencies. Disclosure may be required by law: (1) when there is a reasonable suspicion of abuse/neglect to a child/teen, dependent or elder adult; (2) when the client communicates a threat of bodily injury to self or others or (3) when disclosure is required pursuant to a legal proceeding.
Crescent Comprehensive Clinic does not provide forensic evaluation, does not make recommendations about disability, placement of a child/teen for custody disputes and does not provide investigation or reassessment to reach a determination about child abuse.
I understand that I have the right to refuse services and to discontinue services at any time. Also, Crescent Comprehensive Clinic will discontinue services for the following reasons: 1) the goal(s) of treatment has been successfully achieved, 2) two missed appointments without 48 hour advance notification within 6 months or 3) no contact with the physician more than 90 days. 4) Non Compliance with Treatment 5) Substance Abuse. I understand that I will be financially responsible for any treatment appointments, court reports, appearances or consultations that are required in association with the treatment received from Crescent Comprehensive Clinic.
Patient Signature ______Date______
(18 and above)
Witness Signature______Date______
Crescent Comprehensive Clinic
Client Rights
I understand that as a client of Crescent Comprehensive Clinic I have the following rights:
· To the rights, benefits, responsibilities, and privileges guaranteed by the constitution and laws of the United States and Texas unless they have been restricted by specific terms of law;
· To be treated fairly with dignity and respect without discrimination;
· To receive the most appropriate services;
· To be informed of Crescent Comprehensive Clinic rules and posted hours, especially about how I am expected to behave;
· To communicate in a language that I understand;
· To give input for my own services; (To actively participate in the development and periodic review of an individual treatment and discharge plan where applicable)
· To an explanation of the benefits, effects, other choices and options, and risks of all treatment and medication (if any);
· To refuse or stop services or medication and receive an explanation of possible results of refusing, unless the court orders such;
· To meet with the employees treating me and receive an explanation of their education and training, title, and responsibilities;
· To request an in-house review of care, treatment, and service plan;
· To request at my own expense, the opinion of an expert or consultant to review my services;
· To an explanation of my transfer to another provider outside of Crescent Comprehensive Clinic;
· To receive information about the cost of my services;
· To refuse to participate in research and still receive services at Crescent Comprehensive Clinic;
· To confidential care and treatment;
· To my records being kept in a confidential manner though they are the property of Crescent Comprehensive Clinic, to request access to my records or write an additional note to add in my record by following Crescent Comprehensive Clinic policies and procedures (rules) for such requests;
· To be free from mistreatment, abuse, neglect, and exploitation;
· To have physical, emotional, developmental, educational, social, religious, and spiritual needs met;
· To reasonable protection from theft or loss;
· To not be required to make public statements acknowledging my gratitude to the organization;
· To make a complaint about my services and rights without such complaints being used against me;
· To be given a copy of this statement of client rights so I may refer to it, and/or review it, and understand it;
· To an explanation of any rights that I do not understand. and Affiliated Organizations
· My records and/or any information conveyed by me and/or members of my family to Crescent Comprehensive Clinic personnel will not be released without my written permission unless required by Texas Law. (Reporting alleged or suspected incidents of child abuse is mandatory under the Texas Family Code.)
· While the information belongs to me as a client, the record belongs to Crescent Comprehensive Clinic.
· Crescent Comprehensive Clinic will retain the record under its possession for at least the maximum number of years determined by State and Federal regulatory guidelines.
· Copies or transfer of the documentation within the record may be subject to a fee.
· My rights can only be limited on an individual basis for psychiatric or security reasons. The reasons will be written in my client record, signed, and dated by my physician and fully explained to me:
· If I have a complaint against a licensed physician, I may contact the Texas State Board of Medical Examiners at P.O. Box 2018, MC 263 Investigations, Austin, TX 78788-2018
· I acknowledge that I have read and received a copy of Crescent Comprehensive Clinic Client’s Rights, my rights have been explained to me and I have been given information regarding the reasons that services to my family or me may be involuntarily terminated by Crescent Comprehensive Clinic
Patient (18 yr old or above):______ Date: ______
Parents: ____________Date: ______
Crescent Comprehensive Clinic PLLC
Psychiatric Services
Dr. Farhan Khan M.D.; M.P.H.
Board Certified Adult Psychiatry
Board Certified Child Adolescent Psychiatry
APPOINTMENT POLICY
1. Appointment Fee is due at or before the appointment.
2. You are responsible for appointment fee if paying cash or if insurance refuse to pay.
3. Please keep your contact information up to date.
4. If you are having an emergency, please call 911 or go to the nearest Medical emergency room (ER) or psychiatric hospital.
5. No walk-in appointments are available.
6. Please arrive at least five minutes before appointment time.
7. If you arrive over 15 minutes late to your appointment you may be asked to reschedule unless the physician can accommodate you. Priority will be given to the patients who arrive on time.
8. Your case may be closed for the following reasons:
a. Two “no show” appointments in a 6 month period. A “no show” is any appointment that is missed without 48 hours advance notice.
b. No psychiatric visits in the last 90 days and no documented reason for lack of follow up.
c. Non-Compliance with treatment plan
d. Substance Abuse
I have read, understood, agreed the above stated policy and received a copy of the Crescent Comprehensive Clinic Psychiatric Services appointment policy.
Patient Signature ______Date______
(18yr old and above)
Witness Signature______Date______
Crescent Comprehensive Clinic
Psychiatric Services
472 Park Grove Dr. Katy, TX 77450
Phone: 713-7146371 Fax: 281-476-7830
www.crescentcomprehensive.com
Dr. Farhan Khan M.D.; M.P.H.
Board Certified Adult Psychiatry
Board Certified Child Adolescent Psychiatry
Authorization for Release of Protected Health/Client Information
My health record is private and is known as “Protected Health Information PHI” under the law.
By completing and signing this form, I ______Parent/ Guardian/ Self of ______DOB ______authorize Crescent Comprehensive Clinic Psychiatric Services to obtain/disclose my Protected Health Client Information From/To ______
Address: ______
Phone: ______Fax: ______
I further acknowledge that
· This authorization is voluntary.
· Released information may contain alcohol use, drug abuse, HIV testing /results, or AIDS, chronic disease, communicable diseases or genetic testing information.
· I may revoke this authorization at any time by written request to Crescent Comprehensive Clinic. .
· If permission is cancelled it will not affect actions taken by Crescent Comprehensive Clinic before the permission was revoked.
· Payment, enrollment or eligibility for benefits for my health care will not be affected if I do not sign this form.
· Information disclosed as a result of this authorization may no longer be protected by privacy laws and may be disclosed by the company or individual receiving the information.
To party receiving this information: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure without the specific written consent of the person to whom it pertains, or otherwise permitted by such regulations. A general authorization for the release of information is not sufficient for this purpose FOR CLIENT RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFR PART 2 I, the undersigned, also understand that a copy of this signed authorization form is as acceptable as the original.
Client (18 or above) ______Date ______
Witness ______Date______
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