Sofia Grewal, MD Registration Form

PLEASE READ THROUGH THIS PACKET IN ITS ENTIRETY.

Welcome!

You have been scheduled with Sofia Grewal, MD on at .

We are enclosing paperwork, which is critical to your first appointment.

Please complete the attached forms in full, so we can make sure we have all of the information necessary to address your individual needs and concerns.

Also attached are 3 release forms. 1. One is for your primary care physician (if you have one). 2. The second is for your current or previous therapist/counselor (if you have seen one). 3. The third release is for your most recent past psychiatrist (if you have seen one).

These releases should have the full name of your doctor, their phone number and address.

We must receive this packet (completed) back from you before your Initial Appointment with Dr. Grewal.

Presenting to your initial appointment late or without this packet completed will result in you being asked to reschedule for another date, which may include placement on a waitlist.

We look forward to working with you!

St. Louis Behavioral Medicine Institute

Initial Intake Form

Patient Name: ______Age: ______

Date of Birth: ______Marital Status ▢ Single ▢ Married ▢ Divorced ▢ Widowed

Height: ______Weight: ______Ethnicity: ______

Name of Pharmacy/Zip Code:______

Pharmacy Phone No. ______Primary Care Physician: ______

Why are you currently seeking a psychiatrist? ______

Do you (presently or in the past) suffer from:

1. Depression ▢ No (Skip to #2) ▢ Yes (Please fill out below) Please check any symptoms you’ve experienced that differs from your normal routine: ▢ Change in sleep ▢ Low Energy ▢ Early Morning Awakening ▢ Decreased Concentration ▢ Loss of Interest/ Motivation ▢ Change in Appetite ▢ Lack of interest in things ▢ Difficulty getting out of bed you used to enjoy ▢ Thoughts of being better off dead/ ▢ Feelings of guilt/worthlessness Suicidal thoughts

2. Anxiety/Stress ▢ No (Skip to #3) ▢ Yes (Please fill out below) Please check any symptoms you’ve experienced that differs from your normal routine: ▢ Feeling restless/keyed up or on edge ▢ Increased Irritability ▢ Being easily fatigued ▢ Muscle tension ▢ Difficulty concentrating ▢ Difficulty falling or staying asleep

3. Paranoia/Delusions ▢ No (Skip to #4) ▢ Yes (Please fill out below) Please check any symptoms you’ve experienced: ▢ Feeling harassed by others ▢ Think that others are out to get you ▢ Feeling like you are being watched constantly ▢ Having others tell you you are paranoid/delusional with concern

4. Eating disorder ▢ No (Skip to #5) ▢ Yes (Please fill out below) Please check any symptoms you’ve experienced: ▢ ▢ Restricted food excessively Have purged/thrown up to lose weight ▢ ▢ Have binged on a weekly basis Had others worry about your eating habits

Ver. 10/18 5. Bipolar disease ▢ No (Skip to #6) ▢ Yes (Please fill out below) Please check any symptoms you’ve experienced now or in the past that differs from your normal routine and that occur during the same time period. Symptoms must last for at least 3 days in a row: ▢ Feeling “on top of the world”/extremely irritable ▢ Thoughts are racing ▢ Ability to go without sleep ▢ Inability to maintain focus on a single task ▢ Feeling extremely good about self/Inflated ▢ Starting many tasks at the same time Self-Esteem ▢ Increased sexuality/Impulsive/Spending lots of ▢ Increased Speed of Speech money

6. Hallucinations ▢ No (Skip to #7) ▢ Yes (Please fill out below) Psychosis/Hearing Voices Please check any symptoms you’ve experienced: ▢ Feeling like your mind plays tricks on you ▢ Hearing/seeing things that aren’t there ▢ Feeling like thoughts were placed in your brain ▢ Feeling the TV/Radio/News is relaying a that were not yours message to you specifically

7. Posttraumatic Stress ▢ No (Skip to #8) ▢ Yes (Please fill out below) Disorder Please check any symptoms you’ve experienced currently or in the past that have impacted your ability to function in daily tasks: ▢ Been exposed to an event where you felt like your▢ Avoid things that remind you of the event life was threatened or was horrifically violent (feelings or places/things) ▢ Have intrusive thoughts of the event (nightmares, ▢ Inability to recall parts of the event flashbacks included) ▢ Numbness when talking about the event ▢ Hypervigilant/ Very jumpy since the event ▢ That these symptoms cause significant impairment in your ability to function in task

8. Panic Disorder ▢ No (Skip to #9) ▢ Yes (Please fill out below) If you experienced an abrupt surge of intense fear/discomfort that peaks within minutes, please indicate any other symptoms that occured during that time: ▢ Palpitations, pounding heart, or accelerated heart ▢ Feeling dizzy, unsteady, lightheaded, or faint rate ▢ Chills or heat sensations ▢ Sweating, Trembling or shaking ▢ Numbness or tingling sensations ▢ Shortness of breath/ feeling of choking or ▢ Feelings of unreality smothering ▢ Feeling detached from self ▢ Chest pain or discomfort ▢ Fear of losing control/going crazy/dying ▢ Nausea or abdominal distress

9. OCD ▢ No (Skip to #10) ▢ Yes (Please fill out below) Please check any symptoms you’ve experienced that you’ve acknowledged to be excessive or unreasonable: ▢ Recurrent/persistent thoughts that are ▢ Have repetitive behaviors (e.g., hand washing, intrusive/inappropriate and cause marked ordering, checking) or mental acts (e.g., praying, anxiety/distress counting, repeating words silently) that you are ▢ Try to ignore or suppress such thoughts or to driven to perform to suppress those thought neutralize them with some other thought or action

Ver. 10/18 10. Substance Abuse ▢ No ▢ Yes (Please fill out below) Please check any symptoms you or others have noticed (this include alcohol, illegal drugs and misuse of legal drugs): ▢ Consuming more of the substance than ▢ Still using despite having major consequences originally planned ▢ Placing self in dangerous situations repeatedly ▢ Worrying about stopping/consistently failed when using substance efforts to control one’s use ▢ Giving up activities in favor of drugs/alcohol ▢ Spending alot of time using drugs/alcohol, or ▢ Needing more of the substance to get the same trying to get them feeling over time (Tolerance) ▢ Unable to fulfill major life obligations due to the ▢ Feeling sick when you are unable to use substance ▢ Cravings for the substance

Please list any current psychiatric medications you are on Name of Medication Strength Frequency of Use How Long You’ve Taken It

Please list any other medications you are on currently and did not list above: Name of Medication Dose and Frequency Name of Medication Dose and Frequency

Please list any past psychiatric medication that you have tried below: Name of Medication, Strength and Frequency of use Why Discontinued

Ver. 10/18 Do you currently have a therapist? If so, please indicate who: ______

List any previous psychiatrists and the dates when you saw them: ______

______Have you ever: Attempted Suicide ▢ No ▢ Yes How many times? ______Been hospitalized for psychiatric reasons ▢ No ▢ Yes

If yes, please indicate the dates and reasons: ______

______Self injured (Cut/Burned yourself) ▢ No ▢ Yes If yes, please indicate how and the last time you did so: ______

Please List Any Allergies to Medications: ______

Please check any conditions you currently have:

▢ ▢ Seizures Lung Disease ▢ Clotting Disorder ▢ ▢ History of Head Trauma Kidney Disease ▢ Alzheimer’s Dementia ▢ ▢ Thyroid Condition Liver Disease ▢ Parkinson’s ▢ ▢ Diabetes Chronic Pain ▢ Movement Disorder ▢ ▢ Heart Disease Cancer/ History of Cancer ▢ History of Bariatric Surgery ▢ High Blood Pressure ▢ History of Stroke

Please list any other medical conditions: ______

______

Please list any surgeries you’ve had: ______

______

Has anyone in your family attempted/committed suicide? ▢ Yes ▢No Does anyone in your family has substance abuse issues? ▢ Yes ▢No Please list any family members that have psychiatric issues: Family Member (i.e. grandmother, sister, etc) Psychiatric Illness

Ver. 10/18 Social History: In one word, how was your childhood? ______

What did your parents do for a living? ______

How many Siblings do you have? ______How far did you get in school? ______

What is your current occupation? ______How many Children do you have? ______

Who lives in your home with you? ______

Any Military Experience? ______Who Supports You? ______

Have you ever been to jail? ______Had a DUI? ______Been on Probation? ______

How much of the following do you currently use? (please indicate past use as well) Alcohol Heroin/Opiates

Tobacco Narcotics

Marijuana Benzo

Please list any other medications/drugs that you may misuse ______

______

Have you ever been to rehab/IOP/PHP for your use? ▢ Yes ▢ No Have you had legal consequences due to your use? ▢ Yes ▢ No Have you lost relationships due to your use? ▢ Yes ▢ No Have you suffered at work/school due to your use? ▢ Yes ▢ No

Do you exercise? ______If so, how often? ______

How would you describe your sleep? ______

How would you describe your diet? ______

Is there anything else you would like the doctor to know?

______

Ver. 10/18 PRIMARY CARE PHYSICIAN Request/Authorization to Release Confidential Records and Information St. Louis Behavioral Medicine Institute Central: 1129 Macklind • St. Louis, MO 63110 • 314-534-0200 • Fax: 314-534-7996 West County: 16216 Baxter Road, Suite 205 • Chesterfield, MO 63017 • 636-532-9188 • Fax: 636-532-9951 Patient Name (Printed) Date of Birth ___/___/___

I hereby give ST. LOUIS BEHAVIORAL MEDICINE INSTITUTE permission to execute the following:

OBTAIN, RELEASE, and CORRESPOND my Protected Health Information FROM / TO: Name: Phone Address: Fax:

Email: Relationship to patient:

Permissible means of communications (check all that apply) ☐ALL: ☐Phone ☐ Letter ☐Fax ☐E-Mail Please check requested items: ☐All items can be released ☐ Progress notes ☐ Information about how the patient’s condition affects ☐ Initial Diagnostic Interview ☐ Discharge summary/plan or has affected his or her ability to complete ☐ Psychiatric evaluations ☐ Medication records tasks, activities of daily living, or ability to work ☐ Psychological testing ☐ Billing records ☐ Laboratory data ☐ Admission Summary/plan ☐ Physician’s orders ☐ Alcohol/Drug Abuse Treatment ☐ Treatment plan ☐ Coordination of care ☐ Other: ______TERM OF AUTHORIZATION Purpose of the exchange of information: ☐ to coordinate care ☐ at the request of the individual ☐ Other: Disclaimers: This authorization may be revoked at any time, except to the extent that action will have already been taken upon this authorization. I understand that services provided by SLBMI are not conditional upon my signing this authorization unless the services are provided to me for the purpose of creating health information for a third party. Expiration date:______.

I understand that information used or disclosed pursuant to this authorization may be subject to disclosure by the recipient of your information and may no longer be protected by the HIPPA Privacy Rule. I also understand that if I have any questions or concerns about any part of this form, I can discuss it with an SLBMI staff member prior to signing.

I understand that the exchange of confidential information authorized by this form could include information about any of the following conditions from my medical history: alcohol and drug abuse, HIV/AIDS, psychological, psychiatric or other mental impairment, sickle cell anemia, sexually transmitted diseases, gene-related impairments and other health conditions. It may also include information about how my impairment affects my ability to complete tasks and activities of daily living, and copies of educational testing or evaluations, including individualized educational programs, triennial assessments, speech evaluations and any other records that can help evaluate function. ☐ I agree to provide consent for St. Louis Behavioral Medicine Institute to obtain, release, or correspond my protected health information to the above listed individual / organization.

☐ I decline to provide consent for St. Louis Behavioral Medicine Institute to obtain, release, or correspond my protected health information to the above listed individual / organization. I understand that if my referral source is my (current) healthcare provider, they will be notified of my name, date of birth, and date of my initial appointment with an SLBMI clinician, but no other information regarding my treatment at SLBMI will be provided. X Patient Signature Date Signature of parent or authorized legal guardian Date

Witness Signature Date Notice to those who receive information accompanying this form: This information has been disclosed to you from confidential records and is protected by Federal law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulation. A general authorization for the release of medical or other information is not sufficient for this purpose. NON-SLBMI THERAPIST Request/Authorization to Release Confidential Records and Information St. Louis Behavioral Medicine Institute Central: 1129 Macklind • St. Louis, MO 63110 • 314-534-0200 • Fax: 314-534-7996 West County: 16216 Baxter Road, Suite 205 • Chesterfield, MO 63017 • 636-532-9188 • Fax: 636-532-9951 Patient Name (Printed) Date of Birth ___/___/___

I hereby give ST. LOUIS BEHAVIORAL MEDICINE INSTITUTE permission to execute the following:

OBTAIN, RELEASE, and CORRESPOND my Protected Health Information FROM / TO: Name: Phone Address: Fax:

Email: Relationship to patient:

Witness Signature Date Notice to those who receive information accompanying this form: This information has been disclosed to you from confidential records and is protected by Federal law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulation. A general authorization for the release of medical or other information is not sufficient for this purpose. PREVIOUS PSYCHIATRIST Request/Authorization to Release Confidential Records and Information St. Louis Behavioral Medicine Institute Central: 1129 Macklind • St. Louis, MO 63110 • 314-534-0200 • Fax: 314-534-7996 West County: 16216 Baxter Road, Suite 205 • Chesterfield, MO 63017 • 636-532-9188 • Fax: 636-532-9951 Patient Name (Printed) Date of Birth ___/___/___

I hereby give ST. LOUIS BEHAVIORAL MEDICINE INSTITUTE permission to execute the following:

OBTAIN, RELEASE, and CORRESPOND my Protected Health Information FROM / TO: Name: Phone Address: Fax:

Email: Relationship to patient:

Witness Signature Date Notice to those who receive information accompanying this form: This information has been disclosed to you from confidential records and is protected by Federal law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulation. A general authorization for the release of medical or other information is not sufficient for this purpose. *Please include ALL psychiatric and non-psychiatric medications PAGE 1 ALL MEDICATION & MEDICAL SUMMARY LIST PATIENT NAME: SAINT LOUIS BEHAVIORAL DOB: MEDICINE INSTITUTE

Completed by Patient For Clinician Use Medication Dosage & Medical Prescribing Medication Name* Frequency Condition Physician Notes / If discontinued, Enter Date Date/Initial at Each Review

Signature of Staff Completing Initial Form Date *Please include ALL psychiatric and non-psychiatric medications PAGE 2 ALL MEDICATION & MEDICAL SUMMARY LIST PATIENT NAME: SAINT LOUIS BEHAVIORAL DOB: MEDICINE INSTITUTE

Completed by Patient For Clinician Use Medication Dosage & Medical Prescribing Medication Name* Frequency Condition Physician Notes / If discontinued, Enter Date Date/Initial at Each Review

Signature of Staff Completing Initial Form Date

Revision Date: 5.1.2017 Name: ______Date: ______DOB: ______

PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)

Over the last 2 weeks, how often have you been bothered More Nearly by any of the following problems? Several than half every (Use “✔” to indicate your answer) Not at all days the days day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

Feeling bad about yourself — or that you are a failure or 6. 0 1 2 3 have let yourself or your family down

Trouble concentrating on things, such as reading the 7. 0 1 2 3 newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless 0 1 2 3 that you have been moving around a lot more than usual

Thoughts that you would be better off dead or of hurting 9. 0 1 2 3 yourself in some way

FOR OFFICE CODING 0 + ______+ ______+ ______=Total Score: ______

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult Somewhat Very Extremely at all difficult difficult difficult

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

ST. LOUIS BEHAVIORAL MEDICINE INSTITUTE PATIENT CONSENT REGARDING OUT-OF-POCKET EXPENSES FOR FOLLOW-UP PSYCHIATRY APPOINTMENTS

Psychiatry billing for follow-up services are dependent on services actually rendered during your visit with your psychiatrist. This process is similar to what you may have experienced when you go to your Primary Care Physician – whereas your out- of-pocket expenses per visit can vary depending on what services you need during your appointment. Factors which determine out-of-pocket expenses include (but not limited to) the nature of the appointment, services rendered, symptom complexity, patient needs.

How your psychiatrist bills is much different than how your therapist bills for their time. For example, if you see a therapist for psychotherapy, you will find that your out-of-pockets are (for the most part) the same each time you see them. However, if you see your therapist for a 30 minute session (instead of the 45-minute session) or if your therapist does a different type of service (such as group therapy), then you may then see differences in your out-of-pocket expenses. On the other hand, Psychiatrists, much like Primary Care Physicians, are required to be much more detailed in how they bill for the type of services they provide.

The complexity in psychiatry billing results in a wide range of out-of-pocket expenses that cannot be known until you actually see your psychiatrist and the appointment is completed.

Signature of this document indicates that you (client or representing party) understands that out-of-pocket expenses for follow-up appointments with Psychiatrists will vary across appointments and are based upon actual services rendered in the appointment.

______Client Signature Client Name (please print) Date

______Authorized Representative (if applicable) Name (please print) Date

______Witness Signature Witness Name (please print) Date