Clinical Info
How were you referred to me? *
Have you ever been psychiatrically hospitalized? Have you ever gone to the emergency room for psychiatric reasons? If yes to either, please note what led to it? Also, note how many times and when was the last time? *
Have you ever tried to hurt yourself in any way? Have you ever had a suicide attempt? Have you ever engaged in cutting, burning, or other painful behaviors to relieve emotions? Engaged in any other self-harm? *
Have you ever experienced symptoms of your mind playing tricks on you; like paranoia, hearing things other people didn't or seeing things other people didn't? *
Have you ever had substance/drug/alcohol abuse issues? Have you ever had to do rehab or detox? *
Have you ever felt you needed to Cut down on your drinking/drug use? Have people Annoyed you by criticizing your drinking/drug use? Have you ever felt Guilty about drinking/drug use?Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover? *
Have you ever had a manic or hypomanic episode? Have you ever been diagnosed with Bipolar disorder? *
Have you ever restricted food intake or purged food? Have you ever had an eating disorder? *
Can you please list current and past psychiatric medications? Please also indicate which of these meds you are currently taking. *
Can you please list current and past psychiatric diagnoses, if you have ever been diagnosed with any? *
History of physically hurting others or aggression? Any trouble with the law like getting arrested or into trouble? *
Have you ever had any thoughts of wanting to kill yourself? *Please note:
Have you ever had any thoughts of wanting to kill someone else?
What are your goals for therapy/treatment?
Name preference? Pronoun preference? *
Are you stay-at-home, in school, or working? If in school, what are you studying? If working, what is your profession/job? *
Is there any history or current involvement in any litigation, disability procedures, workman’s comp or custody issues? *
Have you ever been in psychiatric/therapy treatment before? What was the reason for leaving? *
If currently in treatment with a therapist, what's the name of the therapist? *
If stopped seeing a psychiatrist or therapist before, what was the reason? *
*Before submitting the form, please note that this form is NOT for emergency or urgent issues. It is confidential EXCEPT for the following standards all mental health professionals have to follow; All Mental Health Professionals may disclose PHI without your consent or authorization in the following circumstances: 1) Serious threat to Health or Safety-if I believe in good faith that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of you or another identifiable person(s) (if it is an emergency, this may involve emergency room or hospitalization), 2) child abuse, 3) elderly abuse or abuse of an adult who is unable to take care of himself or herself (such as a person with a disability), 4) if you are involved in court proceedings and it is required by a court order, 5) if there is a subpoena from the New York State Board *
•By submitting this form I confirm that I understand that Dr. Chen confirms the use of controlled substances through state prescription management system PMP, as required by law in the state of New York.* *
Do you notice that your mood changes very fast, sometimes within the same day? Do you get angry easily? Do you feel like people are against you? (if so please indicate which of these) *
Scheduling Info
Are there any times that would NOT work for scheduling an appointment? *
Do you have any other scheduling limitations? *
What are the best times and days to call? *
What are the best days and times for a consultation appointment? *
Preferred contact method? Email, Phone, Text? *
What is your email? If you put down an email you are consenting to the use of email as a communication method. This practice is highly electronic and email is used for administrative purposes. Please consider that in terms of fit for you. *
What is your date of birth? *please note that I only treat adults 18 and above. *
•By submitting this form I confirm that I understand that Dr. Chen will reply to this request in a 48 -72 working hours through email. It is not necessary to send a second message or leave a voicemail. This request for appointment, doesn't establish doctor/patient relationship and that all first phone calls and all first appointments are consultation only.* *
How did you hear about my practice? *
Currently all sessions are by telehealth. If there is going to be an in-person option in the future, do you have a preference for office location? Manhattan? Brooklyn? Queens? Either or both depending on the day? Or only telehealth? *
What state are you located in? and will be located in for most of the possible appointments? *
Are you able to do weekly appointments? *
Although I do not take insurances and do not directly work with insurances (thus I am completely out-of-network/private pay), it can be important to know for other things like coverage of labs, prescriptions, etc. What insurance do you have? *
Do you intend to submit a claim to that insurance for the service in order to get possible out-of-network reimbursements by the insurance? *
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