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Long Island Neurocare Therapy
Patient Forms
Book Free TMS Screening
Long Island Neurocare Therapy
Patient Forms
Book Free TMS Screening

New Patient Form

New Patient - TMS Therapy

"*" indicates required fields

MM slash DD slash YYYY
Which location are you visiting today?*
Please chose 1 location
How did you hear about our office?*
My provider is a*
Do you have a diagnosis of Major Depression?*

Patient Information

Name*
MM slash DD slash YYYY
Gender:*
Address*
*I understand that by giving this address, statements and necessary forms will be mailed to the address provided.*
Marital Status*
Education Level*
Occupation*

Emergency Contact Information

May we leave messages with this person:*

Insurance Information

Are you currently seeing a psychiatrist or someone that manages your mental health medication?*
May we contact this person regarding your care here?
Did you ever undergo TMS in the past?
Has therapy helped to resolve depression symptoms?
Do you have current thoughts of*
Do you have current thoughts of*
Any history of suicide attempts?*
Any history of violence?*
Any history of non-suicidal self-injurious behaviors?*
Do you have access to firearms?*
Any history of trauma/abuse?*
Any history of legal problems?*
Have you ever been in remission from depression?*
Have you ever been hospitalized due to your mental health or participated in an inpatient or outpatient program within the last 5 years? Inpatient Psychiatric Hospitalization*
Have you ever been hospitalized due to your mental health or participated in an inpatient or outpatient program within the last 5 years? Intensive Outpatient*

Current Substance Abuse

Tobacco*
Past Tobacco Use*
Alcohol*
Past Alcohol Use*
Recreational Drugs*
Past Recreational Drugs Use*
Have you ever suffered from substance dependence or abuse?*
Do you averagely consume more than 2 alcoholic servings a day?*

Medical Information

May we contact this person regarding your care here?*
Please check all that apply*
Do you have any of the following implants in your body?*
Check all that apply

Brief Symptom Screening Questionnaire

Persistently sad or lost interest in many things that you usually enjoy?*
Frequently anxious, worried, tense, or unable to relax?*
Persistently irritable, angry, hostile, or having mood swings?*
Persistently overjoyed, exuberant, giddy, feeling on top of the world?*
Wished you were dead or had suicidal thoughts?*
Wanted very much to hurt someone else?*
Using alcohol or drugs excessively or felt out of control with them?*
Having recurrent thoughts or nightmares about a traumatic event?*
Hearing voices or having visual hallucinations?*
Feeling suspicious or preoccupied with things others didn’t believe were true?*
Having recurring obsessive thoughts that felt silly but unshakable?*
Engaging in any compulsive behaviors that are hard to stop?*
Having memory problems, difficulty with tasks you used to be able to do, getting lost or confused?*
Are you currently taking any medications?*
Medication Name, Dosage?, Start Date (MM/YY) - End Date (MM/YY), Discontinue Reason
Consent to Treatment*
MM slash DD slash YYYY

The authorization below is given on the patient’s behalf because the patient is either a minor or unable to sign.

MM slash DD slash YYYY
Consent to Treatment*
Initials mean that you agree/consent to terms.
Keeping Appointments*
Initials mean that you agree/consent to terms.
Contacting the Clinic*
Initials mean that you agree/consent to terms.
Confidentiality*
Initials mean that you agree/consent to terms.
Our Agreement*
Initials mean that you agree/consent to terms.
Termination of Treatment*
Initials mean that you agree/consent to terms.
Medicare Primary Coverage (Assignment of Benefits)*
Initials mean that you agree/consent to terms.
Special Circumstances*
Initials mean that you agree/consent to terms.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Agree to Privacy Practices*

To comply with HIPAA standards, each practice must obtain a signed acknowledgement that each direct treatment patient has received its Notice of Privacy Practices and Policies or must document a good faith effort to provide the Notice and receive a written acknowledgement of receipt. This will allow practices to use or disclose confidential information (protected health information) for treatment, payment, or healthcare operations.

MM slash DD slash YYYY
The authorization is given on the patient’s behalf because the patient is either a minor or unable to sign.
MM slash DD slash YYYY

Insurance and Financial Policy

Agree to Insurance and Finacial Policy*

By signing this document, you agree to our policy and acknowledge that you have read and fully understood its contents.

(Parent or guardian, if patient is a minor)
MM slash DD slash YYYY
(Parent or guardian, if patient is a minor)
MM slash DD slash YYYY

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

[This form has been approved by the New York State Department of Health]
MM slash DD slash YYYY
Patient's Address*

Consent to the release of health information pursuant to HIPAA*
Health Provider Address*

Name and address of person(s) or category of person to whom this information will be sent:

Long Island Neurocare Therapy 1739-4 North Ocean Are Medford, NY 11763. (P)631-714-4100 (F)631-714-4191

Specific information to be released:

Ex: 09/12/23 - 11/30/25
*
Include: (Indicate by initialing)*

Authorization to Discuss Health Information

Initials
Name of individual health care provider
(Attorney/Firm Name or Governmental Agency)
Reason for release of information*
MM slash DD slash YYYY
Sigrature of patient or representative authorized by law.

All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.

If not the patient, name of person signing form:
MM slash DD slash YYYY

Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a persca's contacts.