Patient Health Questionnaire (PHQ-9) Todays Date:_____________________
Name:____________________________________________________________________DOB:______________________
Over the last 2 weeks how often have you been bother by any of the following problems?
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
3. Trouble falling or staying asleep, 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 of hurting yourself
+
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?
Not difficult at all
Very difficult
Interpretation of Total Score
Depression Severity
1-4
Minimal depression
5-9
Mild depression
10-14
Moderate depression
15-19
Moderately severe depression
HORIZON BEHAVIORAL HEALTH
ADULT
Patient Information
Patient’s Legal Name: Age: DOB:
Street Address: City/State: Zip:
Birth Gender: Male Female Gender Identity: Male Female Preferred Name:
Social Security #: Driver’s License State and #:
Preferred Phone: Primary Language Spoken:
Is the patient involved in/subject of any active court case to include criminal/custody/divorce: Yes No
If yes please explain:
Responsible Party Information
Responsible Party for Bill:
Street Address (if different than patient): City/ State/Zip:
Preferred Phone: Secondary Phone: Email:
Patient Background
Ethnicity: Hispanic or Latino Not Hispanic or Latino Race – check all that apply: American Indian or Alaska Native
Asian Black or African American Native Hawaiian or Other Pacific islander White Other
Are you currently seeing a therapist: Yes No If yes: Therapist Name:
Therapist Address: Therapist Phone:
Therapist City, State, Zip Code:
Preferred Pharmacy: Primary/Referring Doctor:
Primary Insurance:
Sponsor Social/Member ID/Subscriber# Group #:
Policy Holder Name: DOB: Relationship to Patient:
Secondary Insurance:
Sponsor Social/Member ID/Subscriber# Group #
Policy Holder Name: DOB: Relationship to Patient:
DO YOU HAVE ANY OTHER HEALTH INSURANCE POLICIES: Yes No
**Failure to disclose ALL health insurance policies could result in patient/guardian being responsible for ALL charges in full!*
Signature:__________________________________________ Date:___________________________________
8400 Abercorn Street
Savannah, GA 31406
Phone#: (912)785-2100
Fax#: (844)740-00 09
508 N Main St, Suite A
Hinesville, GA 31313
Phone#: (912)785-2100
Fax#: (844)740-0009
HIPAA FORM: KEEPING YOUR PERSONAL HEALTH INFORMATION PRIVATE
Patient Name:
Daytime contact phone #:
May we leave a message with other residents?
No
Yes:
(Name and relationship)
How would you like to get appointment reminders? You may opt in for email & phone call OR email & text. YOU CANNOT GET A TEXT AND A
CALL!)
Home email: Work email:
Phone call using the following # Text message at the following # May we leave a message on your answering machine or voicemail? No Yes
To whom may we talk to about your medical treatment? Nobody
1.
(Name and Relationship)
(Contact phone #s)
Is this person an emergency contact also?
No
Yes
2.
(Name and Relationship)
(Contact phone #s)
Is this person an emergency contact also? ___No ___Yes
If any of the above information changes, it is the patient/parent/legal guardian’s responsibility to contact our office and make
changes in writing.
(Printed name (relationship if minor)) (Signature) (Date)
RECEIPT OF PRIVACY PRACTICES:
I acknowledge that I was offered and/or received a copy of the Notice of Privacy Practices, and that I have read (or had the
opportunity to read) the document. I acknowledge that I asked (or had the opportunity to ask) any questions regarding the
privacy practices. I understand that I may request a copy of this policy at any time.
(Printed name (relationship if minor)) (Signature) (Date)
www.hbhga.com
595 Towne Park West, Ste 200
Rincon GA 31326
Phone#: (912)785-2100
Fax#: (844)740-0009
508 N Main Street, STE A, Hinesville, GA 31313
8400 Abercorn St, Savannah GA 31406
595 Towne Park West, STE 200, Rincon GA 31326
Phone: (912)785-2100
Fax: (844)740-0009
Patient name: _________________________
Dear Patient,
Thank you for choosing Horizon Behavioral Health, PC (HBH) for your care. Our practice strives to provide
you with the best service for your individual needs, which includes filing your claims with your insurance.
We would like to make you aware that, even though we are “In Network Providers” with most insurances,
our providers do not participate in every insurance plan. In some cases, some of our providers may be in
network with a particular plan and not others. We do not participate at all with some insurance companies.
We will make every effort to process claims with your individual insurance companies to the extent of which
we participate with them. In rare instances, we may be able to file claims on your behalf with your insurance
company even if we do not participate with them.
In some instances, we may be in network with your insurance plan but your particular plan does not cover
some or all services and/or diagnoses. This includes primary and secondary insurances.
It is your responsibility as the patient, to verify your particular plans coverage (and exclusions) for mental
health services with your insurance company prior to your visit. You, the patient, are responsible to pay for
any balance on your account not covered by your insurance.
If your insurance company or insurance plan does not cover your treatment or your diagnosis, but you would
still like to receive services at our office, we will be able to accept you as a self-pay patient.
As a self-pay patient, you will be expected to pay for your visit in full at time of service. A financial statement
about your visit will be available to you for pick up within 7 business days. You may submit this statement
yourself to your insurance company for possible reimbursement to you. We will be able to provide discounts
to you as they become applicable.
I, ____________________________________, have read the above statement and understand that I will be
responsible for any balance on my account prior to being seen. This includes but is not limited to
covered services, covered diagnoses, deductible, co-pay, co-insurance, lab fees, or any other
non-covered charges. HBH will attempt to make you aware of any non-non-covered charges or diagnosis prior to
being seen, however it is not always possible until we receive a final benefits determination from your
insurance company. As a self-pay patient, I understand that I may receive a bill for additional charges after
being seen as it is impossible to know beforehand all the charges that may be involved with each individual
patients care as the level of care required by each patient is different and decided based on the sole
discretion of each provider. I understand that I will receive a financial statement from HBH, which I can file
with my insurance if I choose to do so.
Patient Name:____________________________ Patient DOB:_______________________ Today's Date:_________________ PATIENT HEALTH HISTORY QUESTIONNAIRE
Have you ever had an MRI? Yes No Date: Reason: Have you ever had a seizure? Yes No Date:
List any medical problems that other doctors have diagnosed
Surgeries
Year Reason Hospital
Allergies to medications
Name the Drug Reaction You Had
List your prescribed drugs and over-the-counter drugs, such as vitamins or supplements
Medication Name Dose and Frequency Take Date Started Medication
List any previous psychiatric medications you have been on in the past (antidepressants, ADHD
meds,
etc.)
Medication Name Highest Dose Taken Date Started Date Stopped Reason Why You Stopped Taking
Tobacco
Do you use tobacco? Yes No Cigarettes – pks./day Chew - #/day Pipe - #/day Cigars - #/day # of years Or year quit
Drugs
Do you currently use recreational or street drugs? Yes NoSubstance
Abuse
Treatment
Have you ever received treatment for substance (alcohol or drug) abuse or dependence? Yes No If so, please list the treatment provider/facility and dates: Dates
Caffeine
# of cups/cans per day?None Coffee Tea ColaAlcohol
Do you drink alcohol?If yes, what kind? How many drinks per week? Yes NoAre you concerned about the amount you drink? Yes No Have you considered stopping? Yes No Have you ever experienced blackouts? Yes No Are you prone to “binge” drinking? Yes No Do you drive after drinking? Yes No
Please indicate if you have any of the following:
Aneurysm clips or coils in the head o Yes o No
History of Seizures or Epilepsy O Yes O No
Radioactive seeds o Yes o No
Carotid or cerebral stents o Yes o No
Magnetically programmable shunt valves o Yes o No
DBS electrodes o Yes o No
Metallic devices implanted in the head o Yes o No
Magnetically activated dental implants o Yes o No
Cochlear/otologic implants o Yes o No
CSF shunt o Yes o No
Ferromagnetic ocular implants o Yes o No
Pellets, bullets, fragments o Yes o No
Facial tattoos with metallic ink o Yes o No
Permanent makeup o Yes o No
Staples, sutures o Yes o No
VeriChip microtransponder o Yes o No
Cardiac Pacemaker o Yes o No
Cardiac Stents, filters, valves o Yes o No
Vagus Nerve Stimulator o Yes o No
Wearable infusion pumps o Yes o No
Implanted insulin pump o Yes o No
Single-Tooth Posts o Yes o No
Metal dental braces o Yes o No
Non-removable bridgework o Yes o No
Conductive maxillofacial reconstruction hardware o Yes o No
Titanium Skull plates o Yes o No
Cervical Fixation Device/Cervical Plate o Yes o No
Horizon Behavioral Health
508 N Main St, Suite A ● Hinesville GA 31313 ● Phone: 912-785-2100 ● Fax: 844-740-0009
8400 Abercorn Street ● Savannah GA 31406 ● Phone: 912-785-2100 ● Fax: 844-740-0009
595 Towne Park West, Suite 200● Rincon GA 31326 ● Phone: 912-785-2100 ● Fax: 844-740-0009
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
(Print patient’s full name)
Date of Birth
(Street address) Social Security Number
(City, state, zip code)
I, , hereby authorize:
(Name of provider/facility) (Street address)
(City, state, zip code)
(Phone #) (Fax #) To release the following information to:
Horizon Behavioral Health Horizon Behavioral Health Horizon Behavioral Health
508 N Main St., Ste A 8400 Abercorn Street 595 Towne Park West, STE 200
Hinesville GA 31313 Savannah GA 31406 Rincon GA 31326
Phone: (912) 785-2100 Phone: (912) 785-2100 Phone: (912) 785-2100
Fax: (844)740-0009 Fax: (844)740-0009 Fax: (844)740-0009
Discharge Summary History & Physical Laboratory Results Entire Record
Other:
Purpose of disclosure: Personal Continuing Care Insurance Workers Comp Attorney Other:
If this authorization is for release of medical records, I understand that I am giving my permission to release copies of information in my medical records that may include information relating to psychiatric treatment, drug/alcohol treatment, AIDS/HIV testing, or treatment of sexually transmitted diseases unless indicated in the following instructions:_________________________________ I hereby authorize disclosure of the health information for the above-named patient. This authorization is valid for 12 months from the date of execution. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification cancellation. I understand that there is a retrieval fee of $25.88 per record as well as a per-page fee of $.97 (pp 1-20), $.83 (pp 21-100), $.66 (over 100). I understand that fees are waived when medical records are requested by other health care providers/agencies/facilities for continuing care. All other requests are charged as state and federal laws allow.
Signature of Patient or Guardian Date
Horizon Behavioral Health
508 N Main St, Suite A ● Hinesville GA 31313 ● Phone: 912-785-2100 ● Fax: 844-740-0009
8400 Abercorn Street ● Savannah GA 31406 ● Phone: 912-785-2100 ● Fax: 844-740-0009
595 Towne Park West, Suite 200 ● Savannah GA 31326 ● Phone: 912-785-2100 ● Fax: 844-740-0009
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
(Print patient’s full name)
Date of Birth
(Street address) Social Security Number
(City, state, zip code)
I, , hereby authorize:
ALL PROVIDERS Dr. Afolarin Banjoko Jeffrey Frey, PA-C Marion Curtis, PMHNP-BC Cynthia Casher, PA-C Kellie King, PMHNP-BC Holliy Hollis, PMHNP-BC Katrina Snider, PMHNP-BC Dr. John Adler
Dr. Robert Richardson Dr. Timothy Curran Dr. Odetta Smiley Jonie Gunn, LCSW Michael Porter, LPC To Release records/information to:
(Name of provider/facility) (Street Address)
(City, state, zip code)
(Phone Number) (Fax Number) I authorize the following records to be released:
Discharge Summary History & Physical Laboratory Results Entire Record
PLEASE INCLUDE ALL THERAPY RECORDS _________Other: ___________________________________________ Purpose of disclosure: Personal Continuing Care Insurance
Workers Comp Attorney Other:
If this authorization is for release of medical records, I understand that I am giving my permission to release copies of information in my medical records that may include information relating to psychiatric treatment, drug/alcohol treatment, AIDS/HIV testing, or treatment of sexually transmitted diseases unless indicated in the following instructions:___________________________________ I hereby authorize disclosure of the health information for the above-named patient. This authorization is valid for 12 months from the date of execution. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification cancellation. I understand that there is a retrieval fee of $25.88 per record as well as a per-page fee of $.97 (pp 1-20), $.83 (pp 21-100), $.66 (over 100). I understand that fees are waived when medical records are requested by other health care providers/agencies/facilities for continuing care. All other requests are charged as state and federal laws allow.
Signature of Patient or Guardian Date
Guardian Name Relationship to Patient
