New Patient Intake 2026 New Patient Intake PATIENT INFORMATION Date Legal Name * First Middle Last Preferred Name Date of Birth * Age * Gender * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Cell Phone * Alt. Phone Email * I would like to enroll in the Athena Patient Portal (secure messaging, appointments, refills) Yes No I am a Student * Yes No Highest Degree Occupation Employer Marital Status: * Partner's Name: Emergency Contact Name Emergency Contact Phone Minor / Legal Guardian (if applicable) Parent/Guardian Name: Phone * I attest that I am the legal guardian of the above-named patient and will notify the clinic of any shared custody or guardianship changes. Clinical Information Reason for seeking services: * Referred by: * Previous psychiatric provider: Yes No Previous psychiatric provider: Allergies: Height: Weight: lbs Smoking/Vaping Status: lbs Preferred Pharmacy: * Current Medications Medication * Dose * Schedule * plus1 Add minus1 Remove INSURANCE INFORMATION Concordia Mind Health does not accept Medicaid and Medicare insurance. Self-Pay (No Insurance) If self-pay is selected, insurance information below is not required. Self-Pay rates are $350 for New Evaluation Appointment and $250 for Follow-up appointments. Payments are required to pay in full prior to appointment. Primary Insurance Company: Subscriber Name: Subscriber Relationship to Patient: Self Spouse Parent OtherOther Subscriber's Date of Birth Policy / Member ID #: Group #: Secondary Insurance (if applicable): Subscriber Relationship to Patient: Self Spouse Parent OtherOther Policy / Member ID #: Upload a copy of your insurance card * Drop a file here or click to upload Choose File Maximum file size: 314.57MB Financial & Appointment Policies (South Dakota) Insurance will be billed when applicable; patient is responsible for all charges not covered by insurance. Copayments and self-pay fees are due at the time of service unless prior arrangements have been made. Missed or late-cancelled appointments (less than 24 hours’ notice) will result in a $100 no-show fee, not billable to insurance. Prescription refills require an active follow-up appointment and up to 48 business hours to process. I acknowledge and agree to the clinic’s financial, refill, and no-show policies. Telehealth Consent I consent to receive mental health services via telemedicine when clinically appropriate. I understand: - Telehealth involves electronic communication and may include risks such as technical interruptions. - Sessions may be ended if the connection or environment is unsafe or inappropriate. - I am responsible for being in a private, safe location during telehealth visits. AI-Assisted Clinical Documentation Consent I understand that Concordia Mind Health may use secure AI-assisted dictation technology to support documentation of my mental health visit. AI is used only to assist with note creation. All documentation is reviewed, edited, and approved by my licensed provider. AI does not provide diagnosis, therapy, or clinical decision-making. I may decline or withdraw consent at any time without affecting my care. I consent to AI-assisted documentation I decline Controlled Substance Agreement If prescribed controlled substances, I agree to comply with clinic policies including: - Taking medications only as prescribed and not sharing or altering doses. - Using one designated pharmacy for controlled medications. - No early refills for lost, stolen, or misused medications. - Attending required follow-up appointments and monitoring, including urine or blood testing if requested. Violation of this agreement may result in discontinuation of controlled substance prescribing or care. I acknowledge and agree to the controlled substance policy (if applicable). HIPAA Acknowledgment & Release of Information I acknowledge receipt of the Concordia Mind Health Notice of Privacy Practices, in compliance with HIPAA and South Dakota law. Authorized Individuals (optional) Name Relationship Phone plus1 Add minus1 Remove Consent for Treatment & Communication I consent to evaluation and treatment by Concordia Mind Health. I authorize communication via phone, voicemail, text, or email for healthcare operations, scheduling, and billing purposes, consistent with applicable law. Signature (Covers Entire Intake Packet) By signing below, I acknowledge that I have read, understand, and agree to the information and consents above. Patient Name Patient Name First Name First Name Last Name Last Name Patient or Legal Representative Signature: signature keyboard Clear Date This intake complies with HIPAA, South Dakota telehealth standards, and federal mental health documentation requirements. Submit If you are human, leave this field blank.
