New Patient Intake Form

1. Patient Information

First Name *

Last Name *

Date of Birth *

Gender

Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

2. Emergency Contact

Full Name

Relationship to Patient

Phone Number

3. Insurance Information (if applicable)

Insurance Provider

Policy Number

Group Number

Policyholder's Name

Policyholder's Date of Birth

4. Referral Source

How did you hear about our practice?

Physician Referral

School Referral

Family/Friend

Online Search

Other:

5. Medical History

Primary Care Physician Name

Primary Care Physician Contact

Current Medications

Allergies

Past Medical Conditions

Family Medical History (relevant conditions)

6. Psychiatric History

Previous Psychiatric Diagnoses

Past Psychiatric Medications

Prior Therapy or Counseling Experiences

Family Psychiatric History (relevant conditions)

7. Presenting Concerns

Main Reason for Seeking Treatment

Duration and Severity of Symptoms

Impact on Daily Life

8. Developmental History

To the best of your knowledge

Pregnancy and Birth Details

Early Developmental Milestones

Academic Performance and Challenges

Social Relationships and Peer Interactions

Consents

Consent to Treatment

I consent to receive psychiatric evaluation and treatment from Dr. Van Krasnov, M.D., a board-certified psychiatrist in Adult and Child/Adolescent Psychiatry. I understand that treatment may include psychotherapy, medication management, or both, as clinically indicated. I understand that psychiatry is not an exact science and no guarantees are made regarding outcomes.

Confidentiality

I understand that information shared in treatment is confidential, except in cases where disclosure is required by law:

Imminent risk of harm to self or others
Suspected child, elder, or dependent adult abuse
Court order or subpoena

Emergencies

If I am experiencing a life-threatening emergency, I will call 911 or go to the nearest emergency department. I understand that Dr. Krasnov is not an emergency provider and should not be contacted for urgent crisis management.

Fees

Initial evaluation: $900 (90 minutes)
Follow-up/medication check: $350 (30 minutes)
Therapy + Medication Check: $450 (45 minutes)
After-hours emergency sessions: $700 per hour (rounded to the nearest 15 minutes)
Fees are due at the time of service. I am responsible for payment regardless of insurance reimbursement.

Cancellations & No-Shows

Appointments must be canceled with at least 24 hours' notice. Cancellations with less than 24 hours' notice, or missed appointments, will be charged the full session fee.

After-Hours Communication

Texting or email should be used only for brief, non-clinical matters (e.g. scheduling). Clinical questions or medication concerns require a session. Extended back-and-forth messaging will be redirected to a scheduled appointment. After-hours messages requiring more than a brief response may be billed at the emergency rate listed above.

Telemedicine Consent

I consent to psychiatric treatment via secure video platform when appropriate. I understand the risks and limitations of telemedicine, including technical interruptions and limits to confidentiality.

Controlled Substances Policy (if applicable)

If prescribed controlled medications (such as stimulants, benzodiazepines, or other regulated substances):

Prescriptions will be provided only when clinically appropriate.
Lost or stolen prescriptions will not be replaced.
Early refills are not provided.
Random urine toxicology screens may be required.
Evidence of misuse, diversion, or dishonesty may result in termination of treatment.

Termination of Treatment

Dr. Krasnov reserves the right to terminate treatment for non-payment, repeated missed sessions, threatening or inappropriate behavior, or misuse of services. In such cases, referrals for continued care will be provided.

Coordination of Care

With my written consent, Dr. Krasnov may coordinate with my other healthcare providers (e.g. therapist, primary care physician) when clinically appropriate.

Financial Responsibility

I acknowledge that Dr. Krasnov is an out-of-network provider and does not contract with insurance. I am fully responsible for payment of all fees, regardless of insurance reimbursement.

Acknowledgement

I have read, understood, and agree to these terms. I understand that I may request clarification on any policy at any time.

Signature

Patient Name *

Date *

Signature *

Please sign using your mouse or touch screen

Your care stays entirely human, private, and directly managed by Dr. Krasnov.