Psychiatric Evaluation Intake Request Form

PERSONAL INFORMATION

INSURANCE INFORMATION

REASONS FOR SEEKING SERVICES

Please briefly describe what brings you in today and what concerns you would like support with.

Examples may include:

* Anxiety

* Depression

* ADHD

* Mood Changes

* Stress or Burnout

* Trauma

* Grief & Loss

* Pregnancy or Postpartum Concerns

* Relationship or Family Stress

* Sleep Difficulties

* Other Mental Health Concerns

CURRENT SYMPTOMS

Please check all that apply:

MENTAL HEALTH HISTORY

CURRENT MEDICATIONS

MEDICAL HISTORY

MATERNAL WELLNESS QUESTIONS (If Applicable)

GOALS FOR TREATMENT

Examples:

* Improve emotional wellness

* Reduce anxiety

* Improve mood

* Strengthen coping skills

* Improve focus and concentration

* Heal from trauma

* Improve work-life balance

* Receive support during motherhood

* Improve relationships

* Increase self-confidence

ADDITIONAL INFORMATION

OUR COMMITMENT TO YOU

At Comfort & Clarity Mental Health Services, we understand that reaching out for support can be one of the hardest steps. Our goal is to create a safe, compassionate, and judgment-free space where you feel seen, heard, and supported throughout your healing journey.

We look forward to helping you find comfort in your healing and clarity in your path forward.

Comfort & Clarity Mental Health Services

Compassionate Care. Restored Hope. Lasting Wellness.

TELEHEALTH CONSENT FORM

At Comfort & Clarity Mental Health Services, we are committed to making quality mental health care accessible, convenient, and supportive. Telehealth services allow clients to receive psychiatric evaluations, medication management, therapy, and other mental health services through secure video technology when clinically appropriate.

By signing this form, you acknowledge and agree to participate in telehealth services offered by Comfort & Clarity Mental Health Services.

UNDERSTANDING TELEHEALTH

Telehealth allows you to meet with your provider remotely using a secure, HIPAA-compliant video platform. Telehealth offers flexibility and convenience while maintaining the same commitment to compassionate, high-quality care.

While many clients find telehealth effective and beneficial, there are potential limitations and risks associated with virtual care.

POTENTIAL RISKS OF TELEHEALTH

• Technology failures, interruptions, poor internet connectivity, or equipment malfunctions.

• Potential privacy risks if sessions are conducted on unsecured networks or in non-private environments.

• Limitations in the provider's ability to observe certain physical or non-verbal cues compared to in-person visits.

• Situations where in-person evaluation, emergency services, or a higher level of care may be recommended.

CLIENT RESPONSIBILITIES

• Participate in sessions from a private, quiet, and safe location whenever possible.

• Use a secure internet connection and personal device whenever available.

• Minimise distractions during appointments.

• Provide current physical location and emergency contact information if requested.

• Notify your provider immediately if technical difficulties occur during a session.

MY RIGHTS

• Participation in telehealth services is voluntary.

• You may withdraw your consent for telehealth services at any time.

• You may request in-person services when available and clinically appropriate.

• Telehealth sessions will be conducted using secure technology designed to protect privacy and confidentiality.

CONSENT FOR TELEHEALTH SERVICES

By signing below, I acknowledge that I have read and understand this Telehealth Consent Form. I have had the opportunity to ask questions and voluntarily consent to receive telehealth services through Comfort & Clarity Mental Health Services.

Comfort & Clarity Mental Health Services

Helping you find comfort in your healing and clarity in your journey forward.

INFORMED CONSENT FOR TREATMENT

Welcome to Comfort & Clarity Mental Health Services. We are honoured that you have entrusted us with your care. Seeking support is often one of the most courageous steps a person can take, and we are committed to providing compassionate, evidence-based care in a safe, supportive, and judgment-free environment.

By signing this consent form, you voluntarily agree to participate in mental health treatment services provided by Comfort & Clarity Mental Health Services. Services may include psychiatric evaluations, medication management, psychotherapy, supportive counselling, and maternal mental health services.

UNDERSTANDING TREATMENT

Mental health treatment is a collaborative process designed to help you improve emotional wellness, develop healthy coping skills, gain insight into challenges, and achieve your personal treatment goals.

While many individuals benefit from treatment, no specific outcomes can be guaranteed. Healing requires active participation, honesty, and ongoing collaboration between you and your provider.

APPOINTMENT LENGTH

• Psychiatric Evaluations: Typically 60–90 minutes

• Medication Management Follow-Up Appointments: Typically 15–30 minutes

• Therapy Sessions: Typically 45–60 minutes

• Maternal Wellness Intensive Outpatient Program (IOP): Session lengths vary based on program structure and treatment needs

YOUR RIGHTS

• Ask questions about your treatment at any time.

• Participate in decisions regarding your care.

• Receive respectful, compassionate, and culturally sensitive treatment.

• Decline treatment recommendations or discontinue treatment at any time.

• Be informed of the risks, benefits, and alternatives associated with treatment.

CONSENT FOR TREATMENT

By signing below, I acknowledge that I have read and understand this Informed Consent for Treatment, have had the opportunity to ask questions, and voluntarily consent to receive mental health services from Comfort & Clarity Mental Health Services.

CLIENT POLICIES & AGREEMENTS

Limits of Confidentiality

At Comfort & Clarity Mental Health Services, your privacy is important to us. We are committed to creating a safe, supportive, and confidential environment where you can openly discuss your thoughts, feelings, experiences, and concerns.

Information shared during treatment is kept confidential and will not be disclosed without your written authorization except as permitted or required by law.

Exceptions to Confidentiality:

• Suspected abuse, neglect, or exploitation of a child, elder, or dependent adult.

• A serious risk of harm to yourself.

• A serious risk of harm to another person.

• A court order, subpoena, or other legal requirement mandating the release of records.

• Medical emergencies where disclosure is necessary to protect your safety or the safety of others.

Acknowledgment:

I acknowledge that I have read and understand the Limits of Confidentiality and have had the opportunity to ask questions regarding confidentiality and its limitations.

CANCELLATION & NO-SHOW POLICY

Your appointment time is reserved specifically for you. To provide the highest quality care and accommodate other clients seeking services, we ask that you provide advance notice if you need to cancel or reschedule an appointment.

Appointment Policy:

• A minimum of 24-hour notice is required to cancel or reschedule an appointment.

• Appointments cancelled with less than 24-hour notice may be subject to a late cancellation fee.

• Missed appointments (no-shows) may also be subject to a no-show fee.

• Insurance companies do not reimburse for missed appointments, and any applicable fees are the responsibility of the client.

Acknowledgment:

I acknowledge that I have read and understand the Cancellation & No-Show Policy and agree to its terms.

ELECTRONIC SIGNATURE AGREEMENT

To improve convenience and accessibility, Comfort & Clarity Mental Health Services may utilize electronic forms, records, and signatures.

By signing electronically, I acknowledge and agree that:

• My electronic signature is legally binding.

• My electronic signature has the same legal effect as my handwritten signature.

• I understand the documents I am signing and agree to their contents.

• I voluntarily choose to use an electronic signature for forms and records associated with my care.

Acknowledgment:

I consent to the use of electronic signatures and acknowledge that my electronic signature is valid and enforceable.