Psychiatry Intake

Psychiatry Intake Form

Please complete your demographic information, insurance details, preferred appointment times, and consent. Your information is protected under HIPAA.

Demographics Payment Scheduling HIPAA Consent

Not a crisis service. If you are in immediate danger call 911 or text/call 988 (Suicide & Crisis Lifeline).

Demographics & Contact Information

Basic personal and contact details

First Name *

Last Name *

Date of Birth *

Gender Identity

Pronouns

Race / Ethnicity

Marital Status

Employment Status

Phone Number *

Email Address *

Street Address

City

State

ZIP Code

Referral Source

Emergency Contact

Contact Name *

Contact Phone *

Relationship

Payment & Insurance Information

We accept most major insurance plans and offer self-pay options

Payment Method *

Preferred Appointment Times

Provide 3 preferred dates & times — we'll confirm your appointment by phone or email

Appointment Type

1Preferred Date & Time #1

Date *

Preferred Time *

2Preferred Date & Time #2

Date

Preferred Time

3Preferred Date & Time #3

Date

Preferred Time

Special Accommodations or Notes

HIPAA Notice & Privacy Consent

Your privacy is protected under federal law

Notice of Privacy Practices — Summary

Ndu Balance Psychiatry ("Ndu Balance Psychiatry") is required by the Health Insurance Portability and Accountability Act (HIPAA) to maintain the privacy of your protected health information (PHI) and to provide you with notice of our legal duties and privacy practices.

How We Use Your Information: Your PHI may be used for treatment, payment, and healthcare operations. We may share your information with other treating providers, insurance companies for billing, or as required by law (e.g., mandatory reporting of abuse or imminent harm).

Your Rights: You have the right to inspect and copy your records, request corrections, request restrictions on disclosures, receive an accounting of disclosures, and receive a copy of this notice.

Our Obligations: We are required to abide by the terms of this notice and notify you in the event of a breach of your unsecured PHI.

Telehealth: By using our telehealth services, you acknowledge that electronic communications carry inherent privacy risks and consent to their use for your care.

For the full Notice of Privacy Practices, please call our office at 214-764-6810 or ask your provider at your first appointment.

Authorized Persons: List anyone you authorize Ndu Balance Psychiatry to speak with about your care (name and relationship). Leave blank if none.

Authorized Person(s) to Discuss Your Care

I acknowledge that I have read and understood the HIPAA Notice of Privacy Practices summarized above. I authorize Ndu Balance Psychiatry to use and disclose my protected health information for the purposes of treatment, payment, and healthcare operations as described. *

Signature (Type Full Name) *

Date of Consent *

By submitting this form you confirm all information is accurate to the best of your knowledge.

Please complete all required fields (marked with *) before submitting.