Patient’s Legal Name (as it appears on Driver’s License or Photo ID):
Patient Date of Birth (MM/DD/YYYY):
Social Security Number:
Mailing Address (Street, City, State, ZIP): Patient Gender: MaleFemale
Marital Status:
Email Address: Occupation:
Home Phone Number: Employer:
Cell Phone Number: Employer Phone Number:
Referred to Clinic By: Primary Care ProviderFacebookFamily / FriendInsurance CompanyWeb SearchPrint Ad
Primary Care Provider (PCP) Name: PCP Phone Number (if known):
EMERGENCY CONTACT (Please list anyone you authorize to receive protected health information)
FirstMiddleLast Relationship to Patient: Phone Number:
CUSTODY ARRANGEMENTS (Applicable only to minor children that have court-ordered custody arrangements)
Check this box if you have court-ordered custody arrangements. If checked, please provide court-ordered documents
RESPONSIBLE PARTY INFORMATION (Spouse / Parent / Legal Guardian)
Guarantor on Account
(eg, responsible parent if patient is a minor):
Guarantor Phone Number: Guarantor Relationship to
Guarantor Date of Birth (MM/DD/YYYY): Guarantor Mailing Address (Street, City, State, ZIP):
Primary Insurance Company: Policy/ID Number: Group Number:
Policyholder’s Name: Policyholder’s Date of Birth: Relationship to Patient:
Specialist Copay Amount: $
Secondary Insurance Company: Policy/ID Number: Group Number:
Policyholder’s Name: Policyholder’s Date of Birth: Relationship to Patient:
Patient / Guardian Signature:

Medical History & Intake Form

Patient Name:
Date of Birth (MM/DD/YYYY):
Marital Status:
Are you pregnant? YesNoN/A
Are you breastfeeding? YesNoN/A
List your sexual orientation: StraightGayLesbianBisexualTranssexualN/A
I am looking for help with: ADHDAnxietyBipolarDepressionSleepOther

List any mental health conditions you have been diagnosed with:

List any psychiatric medications you have tried in the past:

List your profession:

List all RX medications you are taking (patients taking 3 or more RX medications are required to provide a printed
med list):

List any allergies to any medications you have:

List any surgeries you have had in the past:

List any medical conditions you have:

If you answer yes to any of the following questions, please explain below:

Have you ever attempted to end your life? YesNo

Have you harmed yourself intentionally? YesNo

Have you been diagnosed with autism? YesNo

Have you ever been to a rehab for drug abuse? YesNo

Have you ever been diagnosed with asthma? YesNo

Have you ever been diagnosed with glaucoma? YesNo

Have you been diagnosed with hyperthyroidism? YesNo

Do you have kidney problems? YesNo

Are you taking opioids or using street opioids? YesNo

Have you been diagnosed with diabetes? YesNo

Do you regularly use Tramadol? YesNo

Have you been hospitalized at a psychiatric hospital? YesNo

Have you ever been diagnosed with a delay? YesNo

Do you suspect you have autism? YesNo

Have you ever been to a rehab for alcohol abuse? YesNo

Do you have cataracts? YesNo

Have you ever been diagnosed with hypertension? YesNo

Have you ever had any heart problems? YesNo

Have you been diagnosed with hypothyroidism? YesNo

Do you have liver problems? YesNo

Have you had seizures in the past? YesNo

Are you taking anti-coagulants (blood-thinners)? YesNo

No-Show & Cancellation Policy

A “no-show” is an appointment for which you do not show up.

It also includes when you change or cancel an appointment less than 24 hours before your scheduled time.

Effective August 12, 2019, there will be a $30 charge for each no-show or change less than 24 hours before your scheduled time.

The fee is charged to the patient, not the insurance company, and is due at the time of the patient’s next office visit.

As a courtesy, when time allows, we make reminder calls for appointments. If you do not receive a reminder call or message, the above policy will remain in effect.

I have read and understand the medical appointment cancellation/no show policy and agree to its terms.

Patient Rights
  1. Expect privacy and respect while you receive your health care.
  2. Always receive polite and respectful care.
  3. Receive health care that is based on American Psychiatric Association standards and guidelines.
  4. Expect timely and reasonable answers to your questions.
  5. Be seen within reasonable time.
  6. Know who is in charge of approving and administering your procedures or treatment.
  7. Know what services are available to help you.
  8. Be given care that is sensitive to one’s developmental needs.
  9. Have access to your medical records.
  10. Be told of medical choices for care or treatment.
  11. Refuse treatment, except that written by law, and to be told of the effects of your choice.
  12. Receive access to medical treatment no matter your race, sex, creed, sexual orientation, nationality, religion, disability or source of payment.
  13. Practice your cultural values and spiritual beliefs as long as they do not interfere with the well-being of others or are within the limits of the law.
  14. Completed information and advice on the financial resources and plans upon request.
  15. A copy of your bill and explanation of charges upon request.
  16. Take part in decision about the plan of your health care.
Patient Responsibilities
  1. Giving true and complete information about your present and past health, and family history.
  2. Telling your healthcare professional of any change in your health.
  3. Providing information to your healthcare professional about any care you received outside of our practice.
  4. Letting us know of any concerns.
  5. Telling your healthcare professional if you do not understand your plan of care and what is expected of you.
  6. Keeping appointments when scheduled, and notifying us in advance if you cannot.
  7. Following the plan of care agreed upon by you and your healthcare professional.
  8. Being responsible for your actions if you refuse treatment or do not follow the agreed upon plan of care between you and your healthcare professional.
  9. Paying your bill.
  10. Being considerate of the rights of others and following office policies.

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.

This practice uses and discloses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.
This notice describes our privacy practices. You can request a copy of this notice at any time. For more information about this notice or our privacy practices and policies, please contact the person listed below.

Treatment, Payment, Health Care Operations

We are permitted to use and disclose your medical information to those involved in your treatment. For example, the provider in this practice is a specialist. When we provide treatment, we may request that your primary care provider share your medical information with us. Also, we may provide your primary care provider information about your particular condition so that he or she can appropriately treat you for other medical conditions, if any.

Your care may also require the involvement of another specialist. When we refer you to another specialist, we will share some or all of your medical information with that provider to facilitate the delivery of care.


We are permitted to use and disclose your medical information to bill and collect payment for the services provided to you. For example, we may complete a claim form to obtain payment from your insurer or HMO. The form will contain medical information, such as a description of the medical service provided to you, that your insurer or HMO needs to approve payment to us.

Health Care Operations

We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered.
For example, we may engage the services of a professional to aid this practice in its compliance programs. This person will review billing and medical files to ensure we maintain our compliance with regulations and the law.

Another example, we may ask another healthcare professional to review this practice’s charts and medical records to evaluate our performance so that we may ensure that only the best health care is provided by this practice.

Disclosures That Can Be Made Without Your Authorization

There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object. In other situations, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and disclosures. However, any revocation will
not apply to disclosures or uses already made or taken in reliance on that authorization.

Public Health, Abuse or Neglect, and Health Oversight

We may disclose your medical information for public health activities. Public health activities are mandated by federal, state, or local government for the collection of information about disease, vital statistics (like births and death), or injury by a public health authority. We may disclose medical information, if authorized by law, to a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may disclose your medical information to report reactions to medications, problems with products, or to notify people of recalls of products they may be using.

We may also disclose medical information to a public agency authorized to receive reports of child abuse or neglect in accordance with State and Federal Law. Regulations also permit the disclosure of information to report abuse or neglect of elders or the disabled.

We may disclose your medical information to a health oversight agency for those activities authorized by law.
Examples of these activities are audits, investigations, licensure applications and inspections which are all government activities undertaken to monitor the health care delivery system and compliance with other laws, such as civil rights laws.

Legal Proceedings and Law Enforcement

We may disclose your medical information in the course of judicial or administrative proceedings in response to an order of the court (or the administrative decision-maker) or other appropriate legal process. Certain requirements must be met before the information is disclosed.

If asked by a law enforcement official, we may disclose your medical information under limited circumstances provided
that the information:

  • Is released pursuant to legal process, such as a warrant or subpoena;
  • Pertains to a victim of crime and you are incapacitated;
  • Pertains to a person who has died under circumstances that may be related to criminal conduct;
  • Is about a victim of crime and we are unable to obtain the person’s agreement;
  • Is released because of a crime that has occurred on these premises; or
  • Is released to locate a fugitive, missing person, or suspect.

We may also release information if we believe the disclosure is necessary to prevent or lessen an imminent threat to the health or safety of a person.

Workers’ Compensation

We may disclose your medical information in accordance with workers’ compensation law.


If you are an inmate or under the custody of law enforcement, we may release your medical information to the correctional institution or law enforcement official. This release is permitted to allow the institution to provide you with medical care, to protect your health or the health and safety of others, or for the safety and security of the institution.

Military, National Security and Intelligence Activities, Protection of the President

We may disclose your medical information for specialized governmental functions such as separation or discharge from military service, requests as necessary by appropriate military command officers (if you are in the military), authorized national security and intelligence activities, as well as authorized activities for the provision of protective services for the President of the United States, other authorized government officials, or foreign heads of state.

Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors

When a research project and its privacy protections have been approved by an Institutional Review Board or privacy board, we may release medical information to researchers for research purposes. We may release medical information to organ procurement organizations for the purpose of facilitating organ, eye, or tissue donation if you are a donor. Also, we may release your medical information to a coroner or medical examiner to identify a deceased or a cause of death. Further, we may release your medical information to a funeral director where such a disclosure is necessary for the director to carry out his duties.

Required by Law

We may release your medical information where the disclosure is required by law.

Your Rights Under Federal Privacy Regulations

The United States Department of Health and Human Services created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several privileges that patients may exercise. We will not retaliate against a patient that exercises their HIPAA rights.

Requested Restrictions

You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment, or healthcare operations. We do NOT have to agree to this restriction, but if we do agree, we will comply with your request except under emergency circumstances.

To request a restriction, submit the following in writing: (a) The information to be restricted, (b) what kind of restriction you are requesting (i.e. on the use of information, disclosure of information or both), and (c) to whom the limits apply. Please send the request to the address and person listed below.

You may also request that we limit disclosure to family members, other relatives, or close personal friends that may or may not be involved in your care.

Receiving Confidential Communications by Alternative Means

You may request that we send communications of protected health information by alternative means or to an alternative location. This request must be made in writing to the person listed below. We are required to accommodate only reasonable requests. Please specify in your correspondence exactly how you want us to communicate with you and, if you are directing us to send it to a particular place, the contact/address information.

Inspection and Copies of Protected Health Information

You may inspect and/or copy health information that is within the designated record set, which is information that is used to make decisions about your care. Your state law may require that requests for copies be made in writing and we ask that requests for inspection of your health information also be made in writing. Please send your request to the person listed below.

We can refuse to provide some of the information you ask to inspect or ask to be copied if the information:

  • Includes psychotherapy notes.
  • Includes the identity of a person who provided information if it was obtained under a promise of confidentiality.
  • Is subject to the Clinical Laboratory Improvements Amendments of 1988.
  • Has been compiled in anticipation of litigation.

We can refuse to provide access to or copies of some information for other reasons, provided that we provide a review of our decision on your request. Another licensed health care provider who was not involved in the prior decision to deny access will make any such review.

Federal and state law requires that we are ready to provide copies or a narrative within a timely manner. We will inform you of when the records are ready or if we believe access should be limited. If we deny access, we will inform you in writing.

HIPAA permits us to charge a reasonable cost based fee. Each Medical Board has set limits on fees for copies of medical records that under some circumstances may be lower than the charges permitted by HIPAA. In any event, the lower of the fee permitted by HIPAA or the fee permitted by the practice’s State Medical Board will be charged.

Amendment of Medical Information

You may request an amendment of your medical information in the designated record set. Any such request must be made in writing to the person listed below. We will respond within 60 days of your request. We may refuse to allow an amendment if the information:

  • Wasn’t created by this practice or the providers here in this practice.
  • Is not part of the Designated Record Set?
  • Is not available for inspection because of an appropriate denial.
  • If the information is accurate and complete.

Even if we refuse to allow an amendment you are permitted to include a patient statement about the information at issue in your medical record. If we refuse to allow an amendment, we will inform you in writing. If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we know have the incorrect information.

Accounting of Certain Disclosures

The HIPAA privacy regulations permit you to request, and us to provide, an accounting of disclosures that are other than for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for an accounting to the person listed below. Your first accounting of disclosures (within a 12 month period) will be free. For additional requests within that period we are permitted to charge for the cost of providing the list. If there is a charge, we will notify you and you may choose to withdraw or modify your request before any costs are incurred.

Appointment Reminders, Treatment Alternatives, and Other Health-related Benefits

We may contact you by telephone, mail, or both to provide appointment reminders, information about your laboratory results, treatment alternatives, or other health-related benefits and services that may be of interest to you.


If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United States Department of Health and Human Services is:

U.S. Department of Health and Human Services
HIPAA Complaint
7500 Security Blvd., C5-24-04
Baltimore, MD 21244

Our Promise to You

We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protected health information, and to abide by the terms of the notice of privacy practices in effect.

Questions and Contact Person for Requests

If you have any questions or want to make a request pursuant to the rights described above, please contact:

Upper Valley Behavioral Health LLC
5690 Santa Teresita Dr., Suite A-2
Santa Teresa, NM 88008-9211
Phone: (575) 332-4115 or Fax: (915) 243-6005

This notice is effective on the following date: January 1, 2019

We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen.

Acknowledgement of Review of
Notice of Privacy Practices

Upper Valley Behavioral Health LLC

I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Patient Name Today’s Date
Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment. Never Rarely Sometimes Often Very Often
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization? NeverRarelySometimesOftenVery Often
3. How often do you have problems remembering appointments or obligations? NeverRarelySometimesOftenVery Often
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? NeverRarelySometimesOftenVery Often
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? NeverRarelySometimesOftenVery Often
6. How often do you feel overly active and compelled to do things, like you were driven by a motor? NeverRarelySometimesOftenVery Often
Part A
7. How often do you make careless mistakes when you have to work on a boring or difficult project? NeverRarelySometimesOftenVery Often
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? NeverRarelySometimesOftenVery Often
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? NeverRarelySometimesOftenVery Often
10. How often do you misplace or have difficulty finding things at home or at work? NeverRarelySometimesOftenVery Often
11. How often are you distracted by activity or noise around you? NeverRarelySometimesOftenVery Often
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? NeverRarelySometimesOftenVery Often
13. How often do you feel restless or fidgety? NeverRarelySometimesOftenVery Often
14. How often do you have difficulty unwinding and relaxing when you have time to yourself? NeverRarelySometimesOftenVery Often
15. How often do you find yourself talking too much when you are in social situations? NeverRarelySometimesOftenVery Often
16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? NeverRarelySometimesOftenVery Often
17. How often do you have difficulty waiting your turn in situations when turn taking is required? NeverRarelySometimesOftenVery Often
18. How often do you interrupt others when they are busy? NeverRarelySometimesOftenVery Often
Part B

Mood Disorder Questionnaire

Name: Date
Please answer the questions as best you can by putting a check in the appropriate box.
1. Has there ever been a period of time when you were not your usual self and … Yes No
… you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? YesNo
… you were so irritable that you shouted at people or started fights or arguments? YesNo
… you felt much more self-confident than usual? YesNo
… you got much less sleep than usual and found that you didn’t really miss it? YesNo
… you were more talkative or spoke much faster than usual? YesNo
… thoughts raced through your head or you couldn’t slow your mind down? YesNo
… you were so easily distracted by things around you that you had trouble concentrating or staying on track? YesNo
… you had much more energy than usual? YesNo
… you were much more active or did many more things than usual? YesNo
… you were much more social or outgoing than usual; for example, you telephoned friends in the middle of the night? YesNo
… you were much more interested in sex than usual? YesNo
… you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? YesNo
… spending money got you or your family into trouble? YesNo

2. If you checked Yes to more than one of the above, have several of these ever happened during the same period of time? Yes No

3. How much of a problem did any of these cause you? (like being unable
to work; having family, money, or legal troubles; and/or getting into arguments or fights)
No Problem Minor Problem Moderate Problem Serious Problem
No ProblemMinor ProblemModerate ProblemSerious Problem

Reference: 1. Hirschfeld RMA, Lewis L, Vornik LA. J Clin Psychiatry. 2003;64(2):161-174.

The Mood Disorder Questionnaire (MDQ) was developed by Robert M. A. Hirschfeld, MD (University of Texas Medical Branch), and published in the Am J Psychiatry. (Hirschfeld RMA, Williams JBW, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11):1873-1875.)

©2009, 2000 Robert M.A. Hirschfeld, MD

UNB124696 06/19