"*" indicates required fields


Your Name:*
Birth Date:
Marital Status:
Parents Name /Legal Guardian if Patient is a Minor:



Is the Patient Covered by Insurance:
Is the Guarantor a Patient Here:
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Patient's Relationship to Subscriber:
Patient's Relationship to Subscriber:


By signing below, I authorize the provider to treat my dependent or myself, to file the insurance on my/our behalf, and to accept assignments on the claims filed. In addition, the above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Achieve MD or insurance company to release any information required to process my claims.



This notice of Privacy Practices describes how we may use and disclose you protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “protected health information” is information about you, including demographic information, that may identify you and that, related to your past, present, or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.


We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services; this includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has necessary information to diagnose or treat you.


Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain for the hospital admission.

Healthcare Operations:

We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at registration desk where you will be asked to sign your name and indicate your physician. WE may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, Public Heath issues as require by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration Requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Sections 164.500.

Other Permitted and Required Uses and Disclosures

Will be made only with Your Consent, Authorization or Opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indication in the authorization.

Your Rights:

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information.

Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information.

This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care of for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request.

If your physician believes, it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use a Healthcare Professional.

-You have the right to request to receive confidential communications from us by alternative means or at an alternative location.

-You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

-You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

-We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.


You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complain. We will not retaliate against you for filing a complaint. This notice was published and in effect on April 14, 2013 We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information, If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.


I hereby authorize Achieve MD to release/share health information and records for the following individual:

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Do We Have Permission To:

Leave a message on your answering machine at home?
Leave a message at your place of employment?
Leave a message on your cell phone?
Discuss your medical information with a member of your family?
If yes, please list family members names:
Column 1
Column 2
Column 3


If there is any additional places or people that may need to request your records or have your records submitted to please state below:

Check all that apply:
Phone No.
Fax No.
Phone No.
Fax No.
The purpose of this disclosure is (check all that apply):

Information to be used or disclosed includes only those items checked below with respect to services provided on or around (dates of service):

If the 'dates of service' field is left blank, the treatment dates covered by this authorization include the date of intake to the last date of service.

Please select below:



Thank you for choosing Achieve MD as your healthcare provider. We are committed to building a successful physician-patient relationship with you. It is important that you have a clear understanding of our patient policies and financial policies. Please understand that payment for services is part of that relationship. It is your responsibility to notify our office of any patient information changes (i.e. address, phone number, insurance, etc.)


Please be prepared to pay your co-pay amount at each visit and have a copy of your current insurance card. We understand you may feel this unnecessary, however insurance plans are becoming more complicated and changes to policies are happening more frequently. In order to file your claims correctly, we must have the most current card on file. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Most plans require we file a claim within 90 days from the date of service. If we have not received your information within that time, you will remain responsible for all charges incurred up to the date you provide us with your insurance information and we received payment from the insurance plan. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance.

Release of Medical Records

Medical records are confidential documents and are only released when permitted by law or with proper written authorization of the patient. Upon request, medical records are released in a timely manner to the patient or the patient’s representative, unless such a release would endanger the patient’s life or cause harm to another person. This includes medical records received from other physicians’ offices or health care facilities.

The following supporting directives are followed when releasing medical information:

1. The patient representatives must have submitted a written request (procedure) or granted written permission before copies of medical information will be released.

2. Achieve MD will not fax or mail medical information to individuals. Medical records must be picked up in person, with valid ID.

3. Achieve MD will not release medical records to patients with an outstanding balance.

4. Achieve MD will implement a 20$ processing fee for release of medical records.

-Self-Pay Account:

Self-pay accounts are patients without insurance coverage, or patients without an insurance card on file with us. If services are paid in full at the time of service, we will apply 20% discount off your charges for that day. This discount does not apply to billed services. Please ask to speak with the billing representative if you are unable to pay your bill in full before you are seen by the physician.

-Methods of Payment

We will gladly accept cash, checks, or credit card (Visa, MasterCard, American Express and Discover) as methods of payment.

-Missed Appointments

Achieve MD requires a 24-hour notice of appointment cancellation. Missed appointments that are not cancelled 24 hours in advanced will be charged a 25$ fee. You will be financially responsible for this fee, as insurance plans do not cover this charge. We do understand that emergencies and/or extenuating circumstances arise occasionally and will work with patients on a case-by-case basis.

-Returned Checks

The charge for a returned check is $30.00 payable by cash, credit card or money order. This fee will be added to the account. Following a returned check, all future payments must be made by cash or credit card as we will no longer be able to accept a check as method of payment.

-Outstanding Balance Policy

It is our policy to collect outstanding balances at each visit. If payment cannot be made in full, you will need to speak with our billing representative. We will send 3 statements on outstanding accounts of $5.00 or more. If payment is not made on the account, it will be sent to the collection agency for processing. Once the account is turned over to the collection agency, a 20% collection fee will be added to the account and the person (18 years and older) financially responsible for the account will also be responsible for all collection’s costs. At this point you may be discharged from our practice.

Please be sure to read this document completely. This financial policy helps our office provide quality care to all of our patients. If you should have any questions, please ask to speak to a billing representative or office manager.

Assessment and/or Testing

Testing is billed on the basis of the type of test and the amount of time necessary to administer, score, analyze, interpret and to report the results in written form. You will be provided with information about the type of test and the cost prior to testing if during the evaluation process it is discovered that additional testing is required to make a final diagnosis, you will be informed before any additional procedures are initiated. The written report is generated after payment in full for testing services is received.


Reports not included in the assessment and/or testing fees will be billed as a separate procedure. Requests for such reports and fees will be discussed with you in advance.

Drug Screen Policy

It is Achieve MD’s policy to perform random drug screenings on each patient. Failure to comply with this policy or tampering with the test could result in the patient’s dismissal from the practice.


Communication between you and your doctor / psychologist is considered privileged and confidential. The only exception to these conditions may occur in situations such as child abuse or danger to your life. Please discuss this with your doctor / psychologist.


I hereby voluntarily apply for and consent to medical services by Achieve MD.This consent applies to myself, ward or client named below. Since I have the right to refuse services at any time, I understand and agree that my continued participation implies voluntary informed consent. I understand that the potential benefits of receiving services may include obtaining a professional opinion, reduction of symptoms and an increased understanding of issues. I understand that potential risks may include possible disagreement with the professional opinions offered, possible emotional distress when addressing my difficulties, and limitations in the ability to make predictions based on results of psychological assessments (when applicable). I understand that alternative procedures include services provided by another psychologist, a psychiatrist, or another health professional. I understand that I may ask for a referral to another health professional if I am not satisfied with my services.

I understand and agree that disclosures and communications are considered privileged and confidential except to the extent that I authorize a release of information or under certain other conditions listed below:

1. Where abuse or harmful neglect of children, the elderly or a disabled or incompetent individual is known or reasonably suspected.

2. Where the validity of a will of a former patient is contested

3. Where such information is necessary for the practitioner to defend against a malpractice action brought by the client.

4. Where an immediate threat of physical violence or suicide against a readily identifiable victim is disclosed to the practitioner.

5. Where the client, by alleging mental or emotional; damages in litigation, put his/her mental state at issue.

6. Where the client is examined pursuant to a court order.



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Possible Impairments:

Please check yes or no:
Poor functioning at work:
Risky sexual behavior:
Frequent job changes:
Unsafe driving (speeding, frequent accidents):
Difficulty managing finances (impulsive spending, poor debt repayment, etc):
Problems in dating or marital relationships:
Legal issues:
Drug abuse/addiction:
Alcohol abuse/addiction:

School History

Please check yes or no:
Dropped out of high school:
Your behavior at school was problematic:
Retained in a grade:
History of poor grades:
Had an individualized Education Plan (IEP) or 504 plan in school:
Have you had psychological or educational testing before:
Been diagnosed with a previous learning disability? (if yes, mention in notes):

Medical History

Please check yes or no:
Are you already diagnosed with ADD/ADHD?
History of head/brain injury:

Current medications that you're on now – please list below:

Column 1
Column 2
Column 3
Column 4

Family Medical History

*Mark any parents, grandparents, aunts, uncles, or sibling diagnosed with any of the following, if yes, write who has it in the yes box*

Bipolar Disorder:
Drug/Alcohol Abuse:
Speech Problems:
Neurological/Tic Disorders:
Learning Disability:
Nerve/Emotional Problems:
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*Please check if you have or has had any of these complaints*

Sleep Problems:
Dental Problems:

Social/Emotional History

Changes in Appetite:
Excessive Mood Swings:
Any Self-Harm:
Violent Behavior:
Obsessive Thoughts:
Compulsive Rituals:
Hyper-Sensitivities to Stimuli (sound, taste, texture, light):
Visual/Auditory Hallucinations:
Suicidal Thinking:
Homicidal Thinking:
Panic Attacks:
Social Isolation:
Have you ever been neglected or physically, verbally, or sexually abused?
Past counseling experience:
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Adult ADHD Self-Report Scale (ASRS-v I , l ) Symptom Checklist

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, check the option 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.


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?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?


7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
I l. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
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?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?
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This field is for validation purposes and should be left unchanged.