Initial Intake Form - Welcome to My Practice

While this form is extensive, it is very helpful to have prior to our first appointment.

Initial Intake

Date*
MM slash DD slash YYYY
Name*
First Middle Name (or Initial) Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
If you like, please let me know your pronouns, sexual orientation and gender identity.
Primary Care Provider Name (Please note that for medication services you must have a primary care provider with whom I can coordinate care if necessary)*
First Last Title
Primary Care Provider Address*
Street Address Address Line 2 City State ZIP Code
Primary Care Provider Telephone#
Primary Care Contact Information: Email (if known)
Therapist Name
First Last Title
Therapist Address
Street Address Address Line 2 City State ZIP Code
Therapist Telephone #
Therapist Email (if known)
Whom may I contact in the event of an emergency?*
First Last
Relationship
- Parent/Relative
- Friend/Roommate
- School Advisor or Other
Emergency Contact Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency contact email and telephone:*
Please describe the key issues for which you are currently seeking treatment and when they began. Please feel free to note situations that are difficult for you, as well as problematic moods, thoughts, and behaviors.
Please list past providers and any previous treatment facilities you received care at
Provider Name/Facility Dates Treated Type of Treatment Reasons for Seeking Treatment
Please describe your current living environment. Who are the members of your current household? Do you anticipate moving or changing addresses within the next year?
Describe your support network: who are the most emotionally supportive people in your life? How would you describe your friendship network? Do you have friends you feel close to? Do they live locally?
Please list members of your family (biological or adoptive)
Name Age Parent, sibling or extended relative? Mental Health or other health concerns?
What are typical things you do for pleasure or enjoyment, and how often?
In my practice, I value who you are and what your lived experiences have been. Please describe cultural, heritage, racial or other identity issues that would be helpful for me to know about you.
Please list any allergies or bad reactions to medicines or foods:*
Medicines Foods Environmental No Known Allergies
Please indicate if you have had any of the following: (i.e. hospitalizations, seizures, autoimmune issues, migraine, GI problems, head injuries, fainting, uncontrolled blood pressure, etc.)
- Medical Hospitalization in past 3 years
- Diagnosed autoimmune disorder(s)
- Migraine
- Seizure
- GI problems, sensitivites
- Head Injury/Loss of consciousness
- Serious accident or injury (motor vehicle or fall, etc)
- Mobility problems
- Fractures (past or present)
- Uncontrolled Blood Pressure
- Other
Please describe your current physical health, health conditions and if you are currently seeing a specialist to treat any medical problems.*
Have you ever taken psychiatric medication(s) before?
- Yes
- No
- Not Sure
As best as you can remember, please list any psychiatric medications you have taken in the past:*
Please describe any issues (or effectiveness) that you experienced with psychiatric medications you have taken. Did they work well? Did you need to stop them for any reason? Would you take them again?*
Are you taking any psychiatric or other prescribed medications currently?
Psychiatric Medications Dose Other Prescribed Medication Dose
I would like to learn about your family history. Are there relatives close to you who have been diagnosed with a mental illness? In some cultures, mental illness is not accepted or discussed in an open way. Is that a concern for you or your family?
Where were you born and raised? Can you briefly describe your experiences in your family growing up? What were your peer relationships like when you were growing up?*
How did you do academically? Where did you complete your education?
Adverse Childhood Events (ACE’s) can have a detrimental effect on your future health. Have you had any of these as a child? (Check all that apply)
Other Stressors (check all that apply)
- None currently
- First Gen
- Financial Worries, Insecurity or Crisis
- Legal Issue(s)
- Insecure Housing
- Insecure Transportation
- Gender Identity
- Gender Affirmation Issues
- Bullied
- Extended Medical Issue, Condition, Illness or Recovery
- Complicated and Uncertain Medical Condition
- Accident Resulting in Injury
- Witness to Violence, Crime or Accident
- Hostile Work Environment
- Unsafe at Home
Many people think about suicide on occasion and it is something I am very open to talk with you about. Have you had times in life where you were thinking a lot about suicide? If so, please briefly describe when, what seemed to be triggering the thoughts, and whether you made a suicide attempt or a suicidal gesture.
Substance Use: Please describe if you have concerns about use, overuse or abuse of alcohol, nicotine, prescription drugs OR have habits /compulsive behaviors that are unhealthy for you:
Please describe if you have any concerns about use, overuse or combined use of any of the following:*
- None or I wish to discuss at Intake
- Social Media
- Alcohol
- Exercise (compulsive)
- Cannabis, CBD products
- Caffeine, energy drinks
- Nicotine (vape, smoke or chew)
- Food (binging, cravings, comfort use, restricting intake)
- Gambling (scratch tickets, casino, online)
- Pornography
- Illicit drugs (designer, synthetics, street drugs)
Can you describe a significant or life changing event(s) that affected you POSITIVELY?
Please upload additional health records, Neuropsychological testing or forms that need to be completed here.
Max. file size: 888 MB.
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Office and Practice Policies*
I have reviewed Ms. Andolina's office and practice policies (listed under Services Tab)
Office Policies
Punctuality: if you find you are running late, I will assume you are on your way and after 15 minutes I will give you a courtesy call to alert you to the missed appointment and the need to reschedule. I tend to run on time with appointments, so please be a few minutes early so you can relax and be present in the session.

Cancellation Policy I have a 48 hour cancellation policy. Prior to 48 hours, there is no cancellation fee; however, if an appointment is missed or cancelled at the last minute, cancellations fees are as follows:

Less than 24 hours notice $100

Less than 48 hours notice $60

In COVID pandemic times I am able to offer telemedicine services. I use a premium Zoom.us, doxy.me or FaceTime platforms. I am able to offer limited in-office visits after July 1st, 2020.

Care Coordination: Within the first several weeks or sooner, I will contact your primary care provider, introducing myself and providing information for the purpose of care coordination.

Communication: It is important that you know how to reach me when I am not in the office. My preferred method of communication is email. Please understand that while email is not a secure form of communication, I recognize the convenience of using it in today’s environment. In the instance where I must communicate with you via email, I will take every precaution to limit personal health information. More secure options for communicating with me are within the messaging options in this website. I make a practice of checking e-mail and voice mail frequently during the weekdays and once daily on weekends. If you do not hear from me within a reasonable period of time, please call or send me a message again.

Complexity and Referral: Treatment should change in response to each persons evolving needs. I continuously pay attention to the need for treatment adjustments as well as the original issues presented. If your condition worsens for any reason, I will help you manage it. If you require a higher level of care, I can provide valuable assistance in accessing that level of care. If the problems extend to beyond my scope of practice, I may refer you to another provider. I have extensive knowledge of the treatment network the Boston and surrounding areas. My goal is to get you the right care, in the right amount and at the right time.

Additionally, it is necessary to involve your primary care provider in care coordination when you are taking medications I prescribe. Additionally, I will occasionally have to be in communication with your insurance company when prior authorizations are needed for medication I prescribe for you.

Medication Management Services: Medication management is best if therapy providers are also part of the treatment experience. If patients are in-between therapy or have challenges finding new providers, medication management can be sustaining but decisions to provide medication services are made on a case by case basis . I provide that service with a number of caveats:

Care Coordination is required with a therapist and/or primary care providers
No long term benzodiazepine prescriptions. Treatment goals should be directed towards lowering and tapering off long term benzodiazepine medications.
I have limited slots for ADHD patients requiring stimulant medications.
Tele-medicine sessions are available during the COVID pandemic and on an availability/appropriateness basis (post Pandemic). A local Primary Care Provider (PCP) would be needed for extended remote treatment where medication management is required.
Overview of Prescription Policies:

Security and Convenience

While I have access to electronic prescribing and reliable resources to check for medication interactions and side effects, it does not substitute for your own efforts to be vigilant in taking medication safely. Please learn about your medication, its uses, dosage and side effects. It is important to know what the tablets look like and to check the information on your bottle for accuracy. It is important to limit alcohol and other drug use as serious interactions can occur.

FDA Approved, Non-Approved and Non-Pharmaceutical Medication Uses and Treatments

The Federal Drug Administration (FDA) provides basic guidelines as to the intended uses of medication, however medications are often approved for a narrow range of indications. I may prescribe medication for non-approved uses (“off-label”) in an effort to safely and judiciously individualize your care. In that instance, I will fully inform you of the reasons for recommending a medication for a non-approved indication and will explain why. I adhere to principles of judicious use, sensible dosing schedules and often will recommend non-pharma options as part of treatment.

Controlled Medications

While all prescribed medications are controlled, some are more controlled then others. Certain medications are under strict quantity and refill limits that vary from state to state. Current pharmacy laws are requiring that many prescriptions be written electronically so as to avoid fraud, diversion and other problems associated with paper prescriptions. Most pharmacies will convert to e-prescribing by 2020 or 2021.

Pharmacy and Pharmacy Benefit Plans

Most insurance companies provides you with a PBM or Pharmacy Benefit Manager (i.e. Medco, ExpressScripts, Bioscript, FutureScripts, etc). These are often large services that are located in other states and provide prescription fulfillment services by mail. They will mail medication quantities as specified on your prescription for either 30, 60 or 90 day increments. In addition, your local pharmacy can fulfill your prescriptions but usually for only 30 or 60 days at a time. Both mail order and local pharmacy providers are instructed to follow the Medication Formulary adopted by your health insurance. That is why some medications I may prescribe will either require a “Prior Authorization” to get it approved, or have a higher co-pay compared to a generic medication. Where possible, I will prescribe generic medications, offer alternatives or seek a prior authorization for the medications I am recommending as part of your treatment plan.

Alcohol

It is important to avoid excess alcohol while taking psychoactive medications. Interactions with psychotropic medications and alcohol have been known to cause “blackouts”, seizures and overdose deaths. Even the “usual amounts” of ingested alcohol can interact dangerously if you haven’t eaten, gotten enough sleep or are dehydrated in any way. Please discuss your patterns of alcohol use while in treatment.

Interactions, Herbs, Supplements , Over the Counter Medicines

Herbs, supplements and over the counter medications can present risks by interfering with the adequate absorption of prescribed medications or increase the blood levels of medications. Please bring a list of herbs, supplements and over the counter medicines to your appointments.
Thank you for completing this Questionnaire! It will be very helpful in developing an effective treatment plan for you. Do you have any questions or is there anything else you would like me to know?
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Provider Name/Facility	Dates Treated	Type of Treatment	Reasons for Seeking Treatment

Name	Age	Parent, sibling or extended relative?	Mental Health or other health concerns?

Medicines	Foods	Environmental	No Known Allergies

Psychiatric Medications	Dose	Other Prescribed Medication	Dose