Nystrom & Associates, Ltd. Psychiatric Medication ......2014/08/02 · Psychiatric Medication Management Consent and Information Form Thank you for choosing Nystrom & Associates,
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Psychiatric Medication Management Consent and Information Form
Thank you for choosing Nystrom & Associates, Ltd. for your care. It is important for you to read each item carefully and initial in the space provided to the left each item. By initialing you are indicating you have read and understand the content of each item. If you have any questions about the items below, please discuss with your provider at your appointment.
General:
_____ I am consenting to be evaluated to undergo possible medication treatment for my mental illness. Medication options will be discussed with your provider. Some of these options may include antidepressants, or psychotropic medications. I may also be recommended to participate in other forms of mental health care treatment.
_____ NAL does not offer after- hours services. If you have a concern, please contact us using FollowMyHealth or by calling your clinic. Your message will first be triaged through our nursing team who will contact you within one business day.
_____ If you have an emergency, such as severe suicidal thoughts, thoughts to hurt someone else, or a severe drug reaction, you should call 911, go to your local urgent care, or go to the emergency room.
_____ Legal guardians must attend all appointments with minors and adult patients who are not their own legal guardians for treatment to occur, unless exceptions have been approved by the Office Manager prior to the appointment.
Medication Refill Requests:
_____ You should contact your pharmacy or use FollowMyHealth first for all medication refill requests.
_____ Refill authorizations can take up to 5 business days.
_____ Controlled medication refills will not be authorized more than 3 days before they are due for refill. If you have questions regarding early refills, please speak with your provider.
Appointment Scheduling and Cancelations:
_____ Appointments canceled without a 24 hour notice may be assessed a fee up to $120.00.
_____ If you miss 3 appointments in a 12 month period with your medication provider, we will end care with you.
_____ You may be able to schedule a same day or cancelation appointment if you 1) have missed your appointment, 2) need forms completed, or 3) have other treatment concerns.
_____ Many of our providers work with medical or nursing students. You should inform your provider if you do not want a student participating in your appointments.
Forms:
_____ Our providers require an appointment to complete any forms. Any forms needing completion should be dropped off at the front desk. Your provider will review the forms and notify staff how long to schedule your forms appointment for. Any forms completed outside of an office visit will be assessed a fee, requiring prepayment.
_____ Your provider will request you complete certain laboratory tests before initiating or continuing certain medications. Laboratory tests may include, but are not limited to: saliva, hair follicle, urine, blood serum, electrocardiograms, psychological testing, genomic testing, etc.
_____ Laboratory testing fees are your responsibility. If your insurance plan will not cover the cost for laboratory, psychological, or other testing, you will be responsible for all costs incurred.
Billing and Insurance:
_____ You are responsible for understanding your insurance coverage.
_____ Co-pays are due at the time of check-in.
_____ Your insurance will be charged for services received. You are responsible for all patient balances due to co-pays, co-insurances, deductibles, tax, billing charges, late or no show charges, laboratory and psychological testing, emergency transportation, etc.
_____ A charge for psychotherapy in addition to a medication management billing code may appear on your billing statement. Psychotherapy is a standard psychotherapy add-on code that all NAL medication providers use to reflect psychotherapy services that occur in session. Psychotherapy is defined in Current Procedural Terminology (CPT) by the American Medical Association as “the attempt to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development” (2012).
Genoa Pharmacy:
We have an on-site pharmacy at our New Brighton, Duluth, Eden Prairie and Woodbury locations to provide you with the convenience of filling all of your medications in the privacy of our clinic. However, Genoa can also fill prescriptions for you at all other locations. Genoa can specially pre-package your medication or mail them to your residence, and they will match the pricing of other pharmacies.
ADHD MEDICATIONS Please note: you MUST have had ADHD testing with a psychologist before we can prescribe these medications. NAL can provide this testing if needed. We do NOT prescribe these medications if you are taking narcotic pain medications, methadone, or suboxone.
Adderall/amphetamine
Adderall XR/amphetamine ER
Concerta/methlylphenidate ER
Daytrana/methylphenidate patch
Desoxyn/methamphetamine
Dexedrine/dextroamphetamine
Dextrostat/dextroamphetamine
Focalin/dexmethylphenidate
Focalin XR/dexmethylphenidate ER
Intuniv/guanfacine
Metadate/methylphenidate
Methylin/methylphenidate
Ritalin/methylphenidate
Ritalin SR/methylphenidate ER
Ritalin LA/methylphenidate LA
Strattera/atomoxetine
Vyvanse/lisdexamfetamine
ANTIANXIETY MEDICATIONS Please note: we do NOT prescribe these medications if you are taking narcotic pain medications, methadone, suboxone, or ADHD medication.
Name: ___________________________ Age: ____ Sex: Male Female Date: ________ If this questionnaire is completed by an informant, what is your relationship with the individual? ___________________ In a typical week, approximately how much time do you spend with the individual? ____________________ hours/week
Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best
describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.
During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?
None Not at
all
Slight Rare, less than a day
or two
Mild Several
days
Moderate More than
half the days
Severe Nearly every day
Highest Domain
Score (clinician)
I. 1. Little interest or pleasure in doing things? 0 1 2 3 4
II. 3. Feeling more irritated, grouchy, or angry than usual? 0 1 2 3 4
III. 4. Sleeping less than usual, but still have a lot of energy? 0 1 2 3 4
5.
Starting lots more projects than usual or doing more risky things than usual?
0 1 2 3 4
IV. 6. Feeling nervous, anxious, frightened, worried, or on edge? 0 1 2 3 4
7. Feeling panic or being frightened? 0 1 2 3 4
8. Avoiding situations that make you anxious? 0 1 2 3 4
V. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 0 1 2 3 4
10. Feeling that your illnesses are not being taken seriously enough? 0 1 2 3 4
VI. 11. Thoughts of actually hurting yourself? 0 1 2 3 4
VII. 12.
Hearing things other people couldn’t hear, such as voices even when no one was around?
0 1 2 3 4
13.
Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
0 1 2 3 4
VIII. 14. Problems with sleep that affected your sleep quality over all? 0 1 2 3 4
15.
Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
0 1 2 3 4
X. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? 0 1 2 3 4
17.
Feeling driven to perform certain behaviors or mental acts over and over again?
0 1 2 3 4
XI. 18.
Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
0 1 2 3 4
XII. 19. Not knowing who you really are or what you want out of life? 0 1 2 3 4
20. Not feeling close to other people or enjoying your relationships with them? 0 1 2 3 4
XIII. 21. Drinking at least 4 drinks of any kind of alcohol in a single day? 0 1 2 3 4
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? 0 1 2 3 4
23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?
This material can be reproduced without permission by researchers and by clinicians for use with their patients.
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COLUMBIA-SUICIDE SEVERITY RATING SCALE
Screener/Recent – Self-Report
In The Past
Month
Answer Questions 1 and 2 YES NO
1) Have you wished you were dead or wished you could go to sleep and not wake up?
2) Have you actually had any thoughts about killing yourself?
If YES to 2, answer questions 3, 4, 5, and 6. If NO to 2, go directly to question 6
3) Have you thought about how you might do this?
4) Have you had any intention of acting on these thoughts of killing yourself,
as opposed to you have the thoughts but you definitely would not act on
them?
5) Have you started to work out or worked out the details of how to kill
yourself?
Do you intend to carry out this plan?
In the Past 3
Months
6) Have you done anything, started to do anything, or prepared to do
anything to end your life?
Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
In your entire lifetime, how many times have you done any of these
Over the last 2 weeks, how often have you been bothered by any of the following problems?
(Circle your answer)
Not at all
Several days
More than half the
days
Nearly every 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
6. Feeling bad about yourself or that you are a failure or
have let yourself or your family down
0 1 2 3
7. Trouble concentrating on things, such as reading the
newspaper or watching television
0 1 2 3
8. Moving or speaking so slowly that other people could
have noticed. Or the opposite- being so fidgety or
restless that you have been moving around a lot more
than usual
0 1 2 3
9. Thoughts that you would be better off dead, or of
hurting yourself
0 1 2 3
Add columns + +
Total:
10. 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?