Enrollment Forms

Please complete each of these forms to the best of your ability.

A patient representative will contact you to complete the process.

1. Enrollment

Personal Information

Emergency Contact

Insurance Information

2. Text Consent

Appointment Reminders

3. HIPAA Privacy Authorization

HIPAA Authorization

Consent for Medical Records Release

4. Authorization to Release Healthcare Information

Personal Information

Emergency Contact

Insurance Information

5. Program Responsibilities

Counseling Agreement

Rescheduling Appointments

6. No Harm Contract

Agreement to not self-harm

7. Medical History

Medications

Illnesses

Hospitalizations

8. Health Questionnaire

PHQ-9

Depression Questionnaire

9. Mood Questionnaire

MDQ

Mood Disorder Questionnaire

10. Anxiety Quetionnaire

GAD-7

General Anxiety Disorder Test

11. ADHD Questionnaire

ASRS - v1.1

Adult ADHD Self Report Scale

Virtual Mental Health Groups​

Monday: 11 am - 12 pm & 5 - 6 pm

Wednesday: 1 - 2 pm

Dial-in: 512-489-3100  Ext. 4820351

  • Facebook Social Icon
  • LinkedIn Social Icon
  • YouTube Social  Icon
For Life-Threatening Emergencies Call 911

Phone: 877-241-2468

Fax: 910-399-2190

© 2019 by Capeside Psychiatry