Skip to main content

Mind Connect Behavioral Health: Intake Questionnaire

Patient Information

Last Name, First Name *
Date of Birth *
Gender *
Marital Status
Street Address *
City*
State *
Zip code *
Email Address *
Phone Number
Upload IDs

* If patient is minor then please upload one of the parents of guardian's ID.

Emergency Contact Information

Name
Phone Number
Relationship to Patient

Insurance Information

Do you have insurance?

Patient History

How did you learn about our practice?
What is the reason for your appointment?
Have you seen a professional who treats mental health concerns before?
Are you currently taking any medications? If yes, list all of them!

Current Symptoms

Sleep
Appetite
Concentration
Energy
Mood
Suicide Thoughts
Suicide Attempts
Self Harm

Notice of Privacy Policies

This notice describes how medical information about you may be used and disclosed. It also describes * how you can get access to this information. Please review it carefully.

In order to provide you care, Mind Connect Behavioral Health (MCBH)/Heta Shah (your "Provider") must collect, create and maintain health information about you, which includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. Your Provider is required by law to maintain the privacy of this information. This Notice of Privacy Practices (this "Notice") describes how your health information may be used and disclosed, and explains certain rights you have regarding this information. Your Provider is required by law to provide you with this Notice, and will comply with the terms as stated.

How Provider/MCBH Uses and Discloses Your Health Information:

Your Provider/MCBH protects your health information from inappropriate use and disclosure, and will use and disclose your health information for only the purposes listed below:

1. Uses and Disclosures for Treatment, Payment and Health Care Operations. Your Provider may use and disclose your protected health information in order to provide your care or treatment, obtain payment for services provided to you and in order to conduct our health care operations as detailed below.

a. Treatment and Care Management. We may use and disclose health information about you to facilitate treatment, and coordinate and manage your care with other health care providers.

b. Payment. We may use and disclose health information about you for our own payment purposes and to assist in the payment activities of other care providers. Our payment activities include, without limitation, determining your eligibility for benefits and obtaining payment from insurers that may be responsible for providing coverage to you, including Federal and State entities.

c. Health Care Operations. We may use and disclose health information about you to support health care functions related to treatment and payment, which include, without limitation, care management, quality improvement activities, evaluating our own performance and resolving any complaints or grievances you may have. We may also use and disclose your health information to assist other health care providers in performing health care operations.

2. Uses and Disclosures Without Your Consent or Authorization. We may Use and disclose your health information without your specific written authorization for the following purposes:

a. As required by law. We may use and disclose your health information as required by state, federal and local law.

b. Public health activities. We may disclose your health information to public authorities or other agencies and organizations conducting public health activities, such as preventing or controlling disease, injury or disability, reporting births, deaths, child abuse or neglect, domestic violence, potential problems with products regulated by the Food and Drug Administration or communicable diseases.

c. Victims of abuse, neglect or domestic violence. We may disclose your health information to an appropriate government agency if we believe you are a victim of abuse, neglect, domestic violence and you agree to the disclosure or the disclosure is required or permitted by law. We will let you know if we disclose your health information for this purpose unless we believe that advising you or your caregiver would place you or another person at risk of serious harm.

d. Health oversight activities. We may disclose your health information to federal or state health oversight agencies for activities authorized by law such as audits, investigations, inspections and licensing surveys.

e. Judicial and administrative proceedings. We may disclose your health information in the course of any judicial or administrative proceeding in response to an appropriate order of a court or administrative body.

f. Law enforcement purposes. We may disclose your health information to a law enforcement agency to respond to a court order, warrant, summons or similar process, to help identity or locate a suspect or missing person, to provide information about a victim of a crime, a death that may be the result of criminal activity, or criminal conduct on our premises, or, in emergency situations, to report a crime, the location of the crime or the victims, or the identity, location or description of the person who committed the crime.

g. Deceased individuals. We may disclose your health information to a coroner, medical examiner or a funeral director as necessary and as authorized by law.

h. Organ or tissue donations. We may disclose your health information to organ procurement organizations and similar entities.

i. For research. We may use or disclose your health information for research purposes. We will use or disclose your health information for research purposes only with the approval of our Institutional Review Board, which must follow a special approval process. When required, we will obtain a written authorization from you prior to using your health information for research.

j. Health or safety. We may use or disclose your health information to prevent or lessen a threat to the health or safety of you or the general public. We may also disclose your health information to public or private disaster relief organizations such as the Red Cross or other organizations participating in bio-terrorism countermeasures.

k. Specialized government functions. We may use or disclose your health information to provide assistance for certain types of government activities. If you are a member of the armed forces of the United States or a foreign country, we may disclose your health information to appropriate military authority as is deemed necessary. We may also disclose your health information to federal officials for lawful intelligence or national security activities.

l. Workers' compensation. We may use or disclose your health information as permitted by the laws governing the workers' compensation program or similar programs that provide benefits for work- related injuries or illnesses.

m. Individuals involved in your care. We may disclose your health information to a family member, other relative or close personal friend assisting you in receiving health care services. If you are available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not available, we will determine whether a disclosure to your family or friends is in your best interest, taking into account the circumstances and based upon our professional judgment.

n. Appointments, Information and Services. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related services that may be of interest to you.

o. Incidental Uses and Disclosures. Incidental uses and disclosures of your health information sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.

3. Special Treatment of Certain Records. HIV related information, genetic information, alcohol and/or substance abuse records, mental health records related to services provided by a New York Article 31 mental health clinic and other specially protected health information may enjoy certain special confidentiality protections (that are more restrictive than those outlined above) under applicable state and federal law. Any disclosures of these types of records will be subject to these special protections.

4. Obtaining Your Authorization for Other Uses and Disclosures. Certain uses and disclosures of your health information will be made only with your written authorization, including uses and/or disclosures: (a) of psychotherapy notes (where appropriate); (b) for marketing purposes; and (c) that constitute a sale of health information under the Privacy Rule. Your Provider/MCBH will not use or disclose your health information for any purpose not specified in this Notice unless we obtain your express written authorization or the authorization of your legally appointed representative. If you give us your authorization, you may revoke it at any time, in which case we will no longer use or disclose your health information for the purpose you authorized, except to the extent we have relied on your authorization to provide your care.

Your Rights Regarding Your Health Information

You have the following rights regarding your health information:

1. Right to Inspect or Get a Copy of Your Medical Record. You have the right to inspect or request a copy of health information about you that we maintain. Your request should describe the information you want to review and the format in which you wish to review it. We may refuse to allow you to inspect or obtain copies of this information in certain limited cases. We may charge you a fee of up to $.15 per page for copies or the rate established by the Department of Health. We may also deny a request for access to health information under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.

2. Right to Request Changes to Your Medical Record. You have the right to request changes to any health information we maintain about you if you state a reason why this information is incorrect or incomplete. Your Provider might not agree to make the changes you request. If we do not agree with the requested changes we will notify you in writing and inform you how to have your objection included in our records.

3. Right to an Accounting of Disclosures. You have the right to receive a list of all disclosures we have made of your health information. The list will not include disclosures made for certain purposes including, without limitation, disclosures for treatment, payment or health care operations or disclosures you authorized in writing. Your request should specify the time period covered by your request, which cannot exceed six years. The first time you request a list of disclosures in any 12- month period, it will be provided at no cost. If you request additional lists within the 12-month period, we may charge you a nominal fee.

4. Right to Request Restrictions. You have the right to request restrictions on the ways which we use and disclose your health information for treatment, payment and health care operations, or disclose this information to disaster relief organizations or individuals who are involved in your care. We are required to comply with your request if it relates to a disclosure to your health plan regarding health care items or services for which you have paid the bill in full, though in other instances, we may not agree to the restrictions you request.

5. Right to Request Confidential Communications. You have the right to ask us to send health information to you in a different way or at a different location. Your request for an alternate form of communication should also specify where and/or how we should contact you.

6. Right to Receive Notification of Breach. You have the right to receive a notification, in the event that there is a breach of your unsecured health information, which requires notification under the Privacy Rule.

7. Right to Paper Copy of Notice. You have the right to receive a paper copy of this Notice of Privacy Practices at any time.

To make a request as described in any of the above, please contact your Provider. Right to File Complaints

If you believe your privacy rights have been violated you may file a complaint with your Provider or with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized or retaliated against by your Provider for filing a complaint.

Changes to this Notice

Your Provider may change the terms of this Notice of Privacy Practices at any time. If the terms of the Notice are changed, the new terms will apply to all of your health information, whether created or received by your Provider before or after the date on which the Notice is changed. Any updates to the Notice will be provided to you.

Please provide your name to signify concurrence. *

Informed Consent for Assessment and Treatment

I understand that I am eligible to receive a range of services from Mind Connect Behavioral Health. The type of extent of services that I receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks.

I understand that I have the right to ask questions throughout the course of treatment and may request an outside consultation. (I also understand that Mind Connect Behavioral Health may provide me with additional information about specific treatment and that I have the right to consent to or refuse such treatment). I understand that I can expect regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment and in the view process. No promises have been made as to the results of this treatment or of any procedures utilized within it. I further understand that I may stop treatment at any time, but agree to discuss this decision first with my provider. 

I am aware that I must authorize Mind Connect Behavioral Health, in writing, to release information about my treatment but that confidentiality can be broken under certain circumstances of danger to myself or others. I understand that once information is released to insurance companies or any other third party, that my provider cannot guarantee that it will remain confidential. When consent is provided for services, all information is kept confidential, except in the following circumstances: 

· When there is risk of imminent danger to myself or another person, my provider/ MCBH is ethically bound to take necessary steps to prevent such danger. 

· When there is suspicion that a child or elder is being sexually of physically abused, or is at risk of such abuse, my provider/MCBH is legally required to take steps to protect the child, and to inform the proper authorities.

· When a valid court order is issued for medical records, my provider/MCBH is bound by law to comply with such requests. 

While this summary is designed to provide an overview of confidentiality and its limits, it is important that you read the Notice of Privacy Practices which was provided to you for more detailed explanations, and discuss with your provider/MCBH any questions or concerns you may have. 

By my signature below, I voluntarily request and consent to behavioral health assessment, care, treatment, or services and authorize my provider/MCBH to provide such care, treatment, or services as are considered necessary and advisable. I understand the practice of behavioral health treatment is not an exact science and acknowledge that no one has made guarantees or promises as to the results that I may receive. By signing this Informed Consent to Treatment Form, I acknowledge that I have both read and understood the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me. 

Please provide your name to signify concurrence. *

Email/Text Consent

I consent to receive text messages or emails from Mind Connect Behavioral Health and their agents on my cell phone or other devices. I understand that text messages and emails sent by Provider may include appointment reminders or changes in previously scheduled


 appointments, or may provide advice or education.


Mind Connect Behavioral Health does not charge for this service, but I understand text messaging rates may apply as provided in my wireless plan. I have been advised that I may contact my carrier for pricing plans and details.


I understand that I may revoke my request for further communications via text or email at any time by notifying Mind Connect Behavioral Health in writing. However, if I continue to communicate with Mind Connect Behavioral Health via text or email, Mind Connect Behavioral Health can assume that my consent remains valid. 


Because e-mails sent over the internet or texts sent over the control channel without encryption are not secure, I understand the risks associated with e-mail and text messaging, including, without limitation, that e-mails and text messages could be intercepted by unknow third parties; e-mail content can be changed without the knowledge of the sender or receiver; backup copies of e-mail may still exist even after the sender and receiver have deleted the messages; and e-mail can contain harmful viruses and other programs. 


Mind Connect Behavioral Health has recommended that I delete all text messages or emails as soon as possible after reviewing them to limit any unauthorized exposure. 


Please provide your name to signify concurrence. *

Telehealth Consent

What is Telehealth?

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services 


I hereby consent to participate in telehealth with, Mind Connect Behavioral Health/Heta Shah, as part of my care. 


I understand that telehealth is the practice of delivering clinical health care services vIa technolog assisted media or other electronic means between a practitioner and a client who are located in two different locations. 


I understand the following with respect to telemental health: 


a. I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled. 


b. There are risks, benefits, and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. 


c. There will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law. 


d. The privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding). 


e. If I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care is required. 


f. Electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.). 


g. During a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call or email me to discuss since we may have to re-schedule. 


h. My therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency. 


i. Electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider's office or to the existing emergency 911 services in my community. 


By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit. 


I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided. 

To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit.


Please provide your name to signify concurrence. *

No-show/late cancellation policy

Appointments are reserved exclusively for each patient. If you are unable to keep your scheduled appointment, we kindly request that you provide at least 24 hours advance notice to cancel or reschedule. You may do so by calling (847)916-7880 or emailing info@mymindconnect.com.  to show up for a scheduled appointment or canceling/rescheduling within 24 hours of the appointment time will be considered a "no-show." For no-show appointments, we reserve the right to charge a $35 fee. Fees for no-shows must be paid prior to booking any future appointments. 


We understand that unexpected circumstances may arise. If you are unable to provide 24 hours notice due to an emergency, please let us know as soon as possible. We will do our best to be accommodating, but reserve the right to apply the no-show fee at our discretion. 

If you have questions about our cancellation policy, please call (847)916-7880 or email at info@mymindconnect.com. 


Please provide your name to signify concurrence. *

PHQ-9 (Depression Assessment)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things *
2. Feeling down, depressed, or hopeless *
3. Trouble falling or staying asleep, or sleeping too much *
4. Feeling tired or having little energy *
5. Poor appetite or overeating *
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down *
7. Trouble concentrating on things, such as reading the newspaper or watching television *
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 *
9. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way *
10. How difficult have these problems made it to do work, take care of things at home, or get along with people? *

GAD-7 (Anxiety Assessment)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Feeling nervous, anxious, or on edge *
2. Not being able to stop or control worrying *
3. Worrying too much about different things *
4. Trouble relaxing *
5. Being so restless that it's hard to sit still *
6. Becoming easily annoyed or irritable *
7. Feeling afraid as if something awful might happen *