Your name

1. Has there ever been a period of time when you were not your usual self and...

you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?	YesNo
you were so irritable that you shouted at people or started fights or arguments?	YesNo
you felt much more self-confident than usual?	YesNo
you got much less sleep than usual and found you didn’t really miss it?	YesNo
you were much more talkative or spoke faster than usual?	YesNo
thoughts raced through your head or you couldn’t slow your mind down?	YesNo
you were so easily distracted by things around you that you had trouble concentrating or staying on track?	YesNo
you had much more energy than usual?	YesNo
you were much more active or did many more things than usual?	YesNo
you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?	YesNo
you were much more interested in sex than usual?	YesNo
you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?	YesNo
spending money got you or your family in trouble?	YesNo

2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? Please check if response only.

YesNo

3. How much of a problem did any of these cause you — like being able to work; having family, money, or legal troubles; or getting into arguments or fights? Please check if response only.

No problemMinor problemModerate problemSerious problem

4. Have any of your blood relatives (e.g., children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?

YesNo

5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

YesNo

6. This questionnaire should be used as a starting point. It is not a substitute for a full medical evaluation. Mood disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your doctor.

This instrument is designed for screening purposes only and is not to be used as a diagnostic tool.

How to Use

The questionnaire takes less than 5 minutes to complete. Patients simply check the yes or no boxes in response to the questions. The last question pertains to the patient's level of functional impairment. The physician, nurse, or medical staff assistant then scores the completed questionnaire.

How to score

Further medical assessment for bipolar
disorder is clearly warranted if patient:

• Answers Yes to 7 or more of the events in question #1

AND

• Answers Yes to question #2

AND

• Answers Moderate problem or Serious problem to question #3

1. ACKNOWLEDGEMENT OF RISKS AND SIDE EFFECTS

Risks and Side Effects of Stimulants (Attention Deficit Medications)

While most patients can safely use stimulant medications for attention deficit problems with appropriate follow-up, the following are known risks and side effects associated with these drugs. This list is not exhaustive but provides an overview of cautions to consider when consenting to treatment.

1. Heart and Circulation Problems: These medications can cause rapid heart rate, elevated blood pressure (sometimes severe), heart attack, long-term heart damage, stroke, and sudden death. The more severe consequences are most likely when the medications are not used as directed. Close monitoring is necessary, especially when starting these medications.

2. Seizures: Convulsions may occur while using these medications.

3. Behavioral Changes: These medications may lead to anxiety, agitation, mood swings, aggressive behavior, mania, or psychotic behavior, especially if not used as directed.

4. Depression: Depression may occur, particularly with misuse and abrupt withdrawal. Notify your doctor if you begin feeling depressed, very sad, hopeless, or suicidal.

5. Tourette Syndrome: A disorder characterized by tics (involuntary movements or vocalizations) that may develop or worsen while on these medications.

6. Allergic Reactions: Like any medication, stimulants can cause allergic reactions, typically within the first few days of use, but sometimes later. Rarely, these medications may lead to life-threatening rashes. Contact your doctor if you experience a rash, swelling, or difficulty breathing.

7. Growth Suppression/Weight Loss: Some children on these medications may experience a slowing in their growth rate; however, it is believed that most will reach their full height eventually. Weight loss can also occur.

8. Gastrointestinal Effects: Patients may experience nausea, vomiting, diarrhea, constipation, dry mouth, abdominal pain, heartburn, and decreased appetite while on these medications.

9. Insomnia: Difficulty sleeping may occur while using these medications.

10. Dependence: Prolonged use may lead to withdrawal symptoms if the medications are abruptly stopped. Symptoms can include many of the behavioral side effects mentioned above, with depression potentially being severe. This issue is more common following misuse or excessive use.

11. Drug Interactions: Avoid alcohol and street drugs such as marijuana, cocaine, speed, or ecstasy, as these can lead to fatal reactions. Additionally, notify your healthcare provider of any new medications prescribed by other healthcare providers.

Risks and Side Effects of Sedative/Tranquilizer Medications

The following are known risks and side effects of sedative/tranquilizer medications. This list is not exhaustive but provides an overview of cautions to consider when consenting to treatment with such drugs.

1. Nausea, Vomiting, and Diarrhea: These effects are generally mild and may improve after the first few days of use.

2. Constipation: This is usually mild and manageable with increased fiber and fluid intake. Notify your doctor if you haven’t had a bowel movement in at least four days.

3. Sedation and Confusion: Patients may experience slowed reflexes, difficulty thinking, an increased risk of falls, fainting, memory problems, and trouble staying awake. These symptoms often improve as the patient adjusts to the medication. Patients should refrain from driving, operating machinery, or engaging in dangerous activities for at least the first week of treatment or after any change in dosage or medication. Caution is advised even after this period.

4. Agitation and Manic Behavior: Some patients may develop agitation or manic episodes while on these medications.

5. Seizures: Convulsions may also occur with sedative medications.

6. Allergic Reactions: Similar to stimulants, sedative medications can cause allergic reactions, usually within the first days of use but sometimes later. Notify your doctor if you experience a rash, swelling, or difficulty breathing.

7. Headaches: Patients may experience headaches or worsening of pre-existing headaches while on these medications.

8. Dependence: Prolonged use may lead to withdrawal symptoms if the medications are abruptly discontinued. Symptoms can include rapid heart rate, irritability, anxiety, agitation, confusion, memory problems, hallucinations, psychosis, seizures, insomnia, tremors, muscle twitching, cramps, stomach discomfort, and sweating. Some withdrawal symptoms can be life-threatening, so it’s important to monitor your medication supply to avoid running out abruptly.

9. Addiction: A craving or psychological desire for these medications may develop with prolonged use.

Note: Always consult your healthcare provider with any concerns about medication use, side effects, or potential interactions with other drugs.

2. AUTHORIZATION FOR THE RELEASE OF INFORMATION
(INSURANCE CARRIER)

I do hereby consent and authorize Thrive Mental Health Services to release all information contained in my financial and medical records, including diagnoses and test results, to my insurance company or health plan, their agents and independent contractors, or any other person or entity that is responsible for paying or processing for payment any portion of my bill, for the purposes of administration, billing and quality and risk management. This consent applies to all records created in the course of and relating to my treatment and for the purpose of reimbursement for treatment.

I understand that I may revoke this consent at any time by giving written notice to the Thrive Psychiatry and Wellness except to the extent that action has been taken in reliance thereon. If no prior notice of revocation is received, this consent will expire six (6) months after the date of patient discharge from treatment, unless another date or condition is specified.

I understand that if I refuse to consent to this Release of Information, the consequences will be that the insurance claim will not be filed.

3. AUTHORIZATION TO BILL INSURANCE

I hereby certify that I have sought evaluation, treatment, or medical advice from the staff at the clinic named above. Therefore, I authorize the medical staff and personnel to release my or my minor child’s medical information to the insurance company listed above for the purpose of determining and receiving benefits for medical bills.

I understand that the medical staff will submit my claim to the insurance company on my behalf. I further acknowledge that I am responsible for any medical bills not covered by my insurance policy, including any deductibles, fees, co-payments, and co-insurance required.

I recognize that any portion of my medical bills not covered by insurance will be billed to me at the address I have provided above. Failure to comply with payment obligations may result in denial of services and/or legal action for non-payment.

We participate in many insurance plans. If you are not insured by a company with which Thrive Mental Health Services does business, or if you do not have an up-to-date insurance card, payment in full is expected at each visit. When you provide Thrive Mental Health Services with current and complete information, Thrive Mental Health Services will bill your primary insurance. Please note that Thrive Mental Health verifies your benefits as a courtesy; this is not a guarantee of payment. We recommend that you confirm your coverage and network status with your insurance company. If your insurance does not pay, you will be responsible for the charges. If you have any questions about your coverage, please do not hesitate to contact your insurance company.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

***I acknowledge receipt of the Notice of Privacy Practices, which explains my rights and the limits on ways my provider may use or disclose personal health information to provide service.

4. BENZODIAZEPINE MANAGEMENT AGREEMENT

The decision to use benzodiazepine medications was made between my provider and myself because of my specific condition.

When I sign this form, I acknowledge that I understand and agree to the following conditions to make my treatment as safe and successful as possible:

1.) I am aware that the use of such medicine has certain risks associated with it, and I have reviewed the Benzodiazepine medication handout with my provider.

2.) I agree to help myself by following better health habits: exercising, controlling my weight, seeking long-term treatments for anxiety, and avoiding the use of alcohol and tobacco, because I realize that good health habits help me control my anxiety and depression.

3.) I agree to tell my doctor about all other medicines and treatments that I am receiving. I will not request or accept controlled substances/medications from any other physician or individual without talking about it with my provider while I am receiving a benzodiazepine medication. To do so may endanger my health and our provider-client relationship. The only exception is medication prescribed while I am admitted to a hospital.

4.) I understand the following refill policy will apply, unless I have made previous arrangements with my provider:

• a. Medications will not be refilled early, even if they have been lost, stolen, or destroyed.

• b. Medications will not be refilled on Fridays, weekends, or holidays.

• c. Medications will not be refilled by other physicians or providers.

5.) I agree to use only one pharmacy for all my medications. If I change pharmacies for any reason, I agree to notify my provider at the time I receive a prescription and inform my new pharmacy of my prior pharmacy’s address and telephone number.

6.) I agree to keep all scheduled appointments.

7.) I must keep my provider fully informed of any changes, ER or PES visits, lost or stolen medications, or any other circumstances affecting my health and well-being.

8.) I have been fully informed by my provider regarding the potential psychological dependence on a controlled substance. I know that some persons may develop a tolerance, which is the need to increase the dose of the medication to achieve the desired effect. I know that I may become physically dependent on the medication. This will occur if I am on the medication for several weeks; when I stop the medication, I must do so slowly and under medical supervision or I may have withdrawal symptoms.

9.) I understand that if I fail to comply with the guidelines in this agreement and on my prescription labels; if I obtain controlled substances elsewhere (even from a physician); if I use illicit drugs; if I share controlled substances with others; or if I alter a prescription, our provider-client relationship will be terminated.

Here at Thrive MHS, providers do not prescribe benzodiazepines for long-term use.

I have read and understand the consequences of violating this agreement. My provider has answered my questions and I agree to the terms of the agreement.

5. CONTROLLED SUBSTANCE POLICY

The purpose of this agreement is to protect your access to controlled substances and to ensure our ability to prescribe them to you. Due to the potential for tolerance, dependence, and side effects, you will need to sign an informed consent when the use of controlled substances is expected to be ongoing. These medications have a high potential for abuse or diversion, which means the prescribing of such medicines is tightly regulated, and we are strictly accountable for our prescribing policies.

A controlled substance is a drug or other substance that the government tightly regulates because it may be abused or cause addiction. This control applies to how the substance is manufactured, used, handled, stored, and distributed. Controlled substances include opioids, stimulants, depressants, hallucinogens, and anabolic steroids.

GENERAL RULES

1. Prescription Management: Medications will be prescribed by Thrive Mental Health Services providers or a covering provider at the practice. Refills for controlled substances will only be issued during appointments.

2. Outside Prescriptions: You will not accept a prescription for a controlled substance from any provider outside of Thrive Mental Health Services, with limited exceptions. If you do accept a prescription, you must notify our office immediately.

3. Pharmacy Selection: You must use only one pharmacy for filling prescriptions. If you need to change pharmacies, you must notify our office.

4. Prescription Security: Prescriptions must be filled at your designated pharmacy, and lost, stolen, or damaged prescriptions will not be replaced.

Medications must not be shared, sold, or used by anyone else and should be taken exactly as prescribed. Mixing these medications with alcohol, non-prescribed sedatives, or illegal drugs is prohibited.

Your provider may request unannounced urine or blood tests. Any evidence of unauthorized drug use, misuse of prescribed medication, or falsified results will be considered a violation of this agreement.

If necessary, your provider may refer you to another specialist. Failure to follow through with referrals will be considered a breach of this agreement.

ACKNOWLEDGMENT AND AGREEMENT

6. INFORMED CONSENT FOR ASSESSMENT AND TREATMENT

I understand that I am eligible to receive a range of services from my provider. The type and extent of these services will be determined after an initial assessment and thorough discussion. The purpose of the assessment is to identify the best course of treatment for me. Generally, treatment is comprehensive, progressive, and requires ongoing assessment and evaluation. My signature below authorizes my mental health provider to treat me. This treatment may include medications, lab tests, diagnostic tests, and educational support. I understand that my provider is available to explain the treatment options, and I have the right to refuse treatment.

I CONSENT to the services rendered by Thrive Mental Health Services, which may include evaluations, consultations, diagnostic testing, clinical therapies, and medication management, if appropriate.

I acknowledge that the success of treatment varies among patients. Providers may determine that certain treatments are likely to help, but there are no guarantees.

Providers may prescribe medications. Not all patients are suitable candidates, and success is not guaranteed. Medications can have side effects, which I will discuss with my provider and pharmacist.

I understand that medication treatment can affect my brain, body, emotions, actions, sleep, memory, judgment, coordination, stamina, and sexuality. Many medications require strict adherence to dosage and frequency.

If I experience unexpected problems, I will inform my provider. In emergencies, I will call 911 or go to an emergency room.

I have had the opportunity to ask questions and have provided my consent voluntarily.

CONFIDENTIALITY & DISCLOSURE

Confidentiality is maintained except in the following cases:

• Risk of imminent danger to myself or another person.

• Suspicion of abuse of a child or elder.

• A valid court order requiring medical records.

I understand that behavioral health treatment is not an exact science and that no guarantees have been made regarding treatment outcomes.

SMS/Text, Mail, and Voice Messaging

I consent to receive SMS messages related to my treatment, including appointment reminders.

ACKNOWLEDGMENT OF PRIVACY PRACTICES

I acknowledge receipt of the Notice of Privacy Practices, which explains my rights and how my provider may use or disclose personal health information.

7. MEDICATION REFILL POLICY

At Thrive Mental Health Services, we are committed to supporting you on your journey toward stability, mental wellness, and happiness. We believe that our partnership with you is vital in achieving these goals. To make this process easier, we’ll ensure that you can schedule your follow-up appointment before leaving your current visit. If there’s ever a need to change or cancel your appointment, we promise to maintain your medication coverage until your next visit. Our providers will prescribe enough medications to last you until your upcoming appointment, removing the hassle of having to call in for refills.

We understand the complexities that sometimes come with insurance processes, and we will work diligently with your medical insurance providers to ensure that you never go without your medication due to paperwork delays or requirements such as prior authorizations or medical necessity forms.

While we do not offer medication refills outside of scheduled appointments, we understand that life can throw unexpected challenges your way. If you find yourself in a situation where you need medication outside of your appointment time, we are here to help! Please note that a nominal fee of $15 will apply for prescriptions filled outside your scheduled visits, and this amount is due at the time of your request. Additionally, to ensure we can assist you effectively, medication refill requests that occur outside of appointments will require 48 business hours to process.

Our primary aim is to anticipate your needs proactively, ensuring you have sufficient medication until your follow-up visit. This approach is designed to save you time from unnecessary login attempts on the Patient Portal for refill requests. However, should you ever need to reach out for a refill or schedule an appointment, our online patient portal is always available to assist you.

PATIENT RESPONSIBILITIES

As part of our partnership, I agree to uphold the following responsibilities regarding my medications:

• I take personal responsibility for managing my medicines.

• I understand that sharing, selling, or trading my medication is not permitted.

• I will never take someone else’s medication.

• I will only adjust my medication dosage after consulting with my provider or office associate.

• I acknowledge that lost or stolen medications will not be replaced if used up sooner than prescribed.

• I will attend all scheduled appointments and arrive on time. I recognize that arriving more than 5 minutes late will be considered a no-show.

• If requested, I agree to provide a blood, urine, or buccal swab sample for drug testing purposes.

I confirm that I fully understand the office’s medication policy.

8. OFFICE POLICY

Please read and initial the following statements concerning our office policies:

I certify that the information I have given on this form is true and correct to the best of my knowledge.

I understand that if I arrive more than 10 minutes late for an appointment, it is not guaranteed that I will be seen. A $75.00 no-show fee will be charged if the schedule does not allow for me to be seen.

I understand that payment is required at the time services are rendered and I assume responsibility for this. I understand there is a $30.00 fee for all returned checks.

I understand that insurance will only be filed with insurance companies that Thrive Mental Health is contracted with. I must have all current insurance information on file. I understand that secondary insurance will not be filed.

I understand that if there are any changes in my insurance coverage, I will notify the business office at least five (5) days prior to my next appointment or the visit will be self-pay or rescheduled.

I understand that all information obtained regarding my insurance is not a guarantee of payment by my insurance company. I am ultimately responsible for any and all balances on my account.

I understand it is my responsibility to keep my appointments. If I cannot keep my appointment, I will notify the office at least 24 hours in advance. I understand that I will be charged $75.00 for the time reserved if I do not call and cancel or reschedule at least 24 hours prior.

I understand that regular office hours for Thrive Mental Health Services are Monday – Thursday, 9 AM – 5 PM.

I understand it is my responsibility to track my medication supply. Requests received outside regular business hours will not be processed until the next business day. A 2-business-day notice is required for prescription refills.

I understand that my records are protected by special laws governing psychiatric/substance abuse records and that I must sign a 'Release of Information' form before any records can be released.

I understand that providers do not appear in court to defend patients/clients. If a subpoena is issued, I am responsible for paying $1,500.00 for a half-day or $3,000.00 for a full day in court, collected in advance.

I understand that providers do not perform mental evaluations for court cases.

I understand the requirement for scanning/making a copy of my ID and insurance card for medication dispensation, billing, and identification purposes.

I understand that Thrive Mental Health Services has the right to terminate patients who are non-compliant with office policies, including multiple no-shows without notice, frequent tardiness, and losing or discarding medications.

I understand that there is no after-hours answering service. In case of an emergency, I must call 911 or go to the nearest Emergency Room.

CONSENT FOR SERVICES

I hereby authorize Thrive Mental Health Services to provide psychiatric services to:

9. OUT-OF-POCKET RATES

– Initial Evaluation: $300

– Follow-up Appointment: $150

– Medical Paperwork (FMLA, DMV Forms, ESA Letters, and other requests): $50

Note: Thrive Mental Health Services does not complete disability forms. However, with informed consent, we will assist in releasing your medical records for review.

10. NOTICE OF PRIVACY PRACTICES

This Notice outlines how your medical information may be used and shared, and how you can access it. Please read it carefully.

How Your Provider May Use and Disclose Your Health Information:

• For Treatment: Your PHI may be shared with those providing your care to coordinate treatment. Authorization is required for disclosure to other consultants.

• For Payment: Your PHI may be used to obtain payment for services, including processing insurance claims.

• For Health Care Operations: Your PHI may be used for business activities such as quality assessments.

• Required by Law: Your PHI will be disclosed as mandated by government agencies or court orders.

• Without Authorization: Limited disclosures may occur without your consent for legal requirements or safety threats.

• With Authorization: Any other uses or disclosures require your written consent, which you may revoke.

Your Rights Regarding Your PHI:

• Right to Access and Copy: You can inspect and copy your PHI unless access could cause you harm.

• Right to Amend: You can request corrections to inaccurate or incomplete PHI.

• Right to an Accounting of Disclosures: You can request a list of certain disclosures of your PHI.

Complaints:

If you believe your privacy rights have been violated, you may submit a complaint with the Federal Government:

Secretary of the U.S. Department of Health and Human Services

200 Independence Avenue, SW

Washington, DC 20201

(202) 619-0257

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices, which explains my rights and the limits on ways my provider may use or disclose personal health information to provide service.

By signing below, I acknowledge my understanding of the information provided, and I am aware that I can access a copy of my consent forms anytime through my patient portal or request one from the office staff. Thank you for being an important part of our Thrive community; we look forward to supporting you!