WCLC

THIS FORM MUST BE COMPLETED BY THE POTENTIAL PATIENT: IT MAY BE COMPLETED WITH THE ASSISTANCE OF ANOTHER PERSON AS LONG AS THE PATIENT AGREES WITH ALL THAT IS STATED AND VOLUNTARILY SIGNS THE BOTTOM OF THE DOCUMENT WITH THEIR
TYPED NAME AND EMAIL ADDRESS

Pre-Consult Questionnaire - Potential Patient

DIRECTIONS: Before taking the time to complete this form or schedule your free 10 minute pre-visit with Dr. Stein, carefully review the following:

Kira Stein MD, APC (West Coast Life Center) is a private fee-for-service medical practice that does not contract with health insurance, MediCal or MediCare. This allows Dr. Stein to spend more time to focus on patient care. Patients can submit superbills (receipts for insurance claims) to PPO insurance for out-of-network reimbursement, but not to HMO, MediCare or MediCal. Check with your insurance for their coverage details. Dr. Stein and the practice is not responsible for denial of coverage or for appealing denials.

BASIC FEES AND SERVICES (More Detailed Fee Schedule Available on Client Portal):

• 10 min pre-consult by phone or teleconference: $0
• 90 min initial psychiatric consultation: $850 (CPT code 90792)
• Standard "3/4 hour" appointments: $475 (CPT code 90215)
• Between-Visit Prescription Refills(requires 48 business hours’ notice): $20 for non-controlled; $50 for controlled.
• Missed Visits or appointments canceled with less that 48 business hours’ notice: Patients are responsible for, and are charged, the full fee of the missed reserved appointment.

I agree with all of the above and understand that this is not an all-inclusive list of all the office policies. More details are found in the registration forms provided prior to the initial comprehensive evaluation.

I accept and understand that this web form submission is part of an application for a non-urgent outpatient psychiatric consultation and does not constitute a doctor-patient treatment relationship. The information I am providing on this form and during my complementary 10 minute pre-consult will help Dr. Stein decide if an outpatient consultation with her is appropriate or if a different referral will better serve my needs.

If my situation is life-threatening, or an emergency that cannot wait for a response, I should call 911 or go to the nearest emergency room instead of submitting this form.

I understand that this submission will not be reviewed after hours or when Dr. Stein is out of the office.

I understand that it is my responsibility to check Dr. Stein's office at (310) 529-6051 to see if she is out of the office. I understand that, if she is out of the office, I am unlikely to have this submission reviewed until 2 days after she returns.

Demographic Information:

* First Name

* Last Name

* Date of Birth

- Dr. Stein does not treat individuals under the age of 18 years.

* What is your gender?

* Mobile Telephone:

Home Phone:

* Email address (home):

* Residential Address (street number & name), city, zip, state)

* Please detail your marital status:

SIngle/Never Married Single/Divorced Married

* Please detail your employment status:

Employed Part-Time Employed Full-Time Student Unemployed On Disability (Reason and length of time disabled)

Reason and length of time disabled

* Who is your primary care physician?

Name

Phone Number

* I give Kira Stein MD APC permission to send me detailed messages in the following manner(s) so Dr. Stein can answer questions and request clarification about my background, medical and psychiatric history and symptoms. This will help determine if it is appropriate to schedule an initial comprehensive evaluation consult with Dr. Stein. I understand and agree that I will not hold Dr. Stein and staff liable for breaches of confidentiality caused by myself, by any lack of privacy or electronic security on my end, or by another third party.

Voicemail on Cell Phone Voicemail on Home phone SMS Text on my mobile phone (less secure but very convenient) Home Email, unencrypted (more convenient/easier access, but less secure) Home Email with (extra secure encryption but more cumbersome to open as a result)

* What are your goals regarding psychiatric care?

CURRENT/RECENT HISTORY

* Why are you seeking consultation from a psychiatrist at this time? Is there something specific, such as a particular event you have been struggling with? What are your symptoms? Be as detailed as you can.

* Please check any of the following problems you have experienced in the past six months:

Please provide details

If others please specify

* Do you have thoughts or urges to harm others?

Yes No

If Yes, please describe your thoughts and how frequently and intensely they occur. NOTE: If you cannot wait for an in-person scheduled outpatient consultation, call 911 or go to your nearest emergency room.

* Do you currently have serious thoughts of intentionally ending your life?

Yes No

It Yes, please describe thoughts and when was the last time such a thought occurred. NOTE: If you cannot wait for an in-person scheduled outpatient consultation, call 911 or go to your nearest emergency room.

* Do you have access to a firearm?

Yes No

What type? For what purpose? Where do you keep it?

* Please select any of the following physical conditions or diagnoses you have:

Please list how many months you have been pregnant and your due date here:

Please list location and date of delivery here:

Please provide details here:

Please detail your other physical conditions/diagnoses that we did not list here:

* Do you have any medication allergies?

Yes No

If yes, list medications and type of reaction:

* Are you on any medications or supplements?

Yes No

* Specify all medications, including supplements you are presently taking and for what reason. Please detail your doses.

* Do you drink alcohol?

Yes No

If Yes, Describe type, amount, frequency

* Do you use recreational drugs? (including medical marijuana)

Yes NO

If Yes, Describe type, amount, frequency

*Do you use sedatives like benzodiazepines (eg Ativan, Valium, Clonazepam) or opiates (eg vicodin, fentanyl, heroine) or stimulants ( eg Adderal or Ritalin, or other forms), or Cocaine or Meth?

Yes No

How many mg of each drug per day and for how long? Which drugs were prescribed by doctors?

* Do you or anyone else you know think you use substances, sleep, food, pornography, sex, electronics, video games, or anything else in order to "check out" or numb yourself from feeling pain or distress?

Yes No

If so please detail type of avoidance, how often, how long and when it occurs and any other details.

PAST HISTORY

* Have you ever been physically violent with another person ?

Yes No

If Yes, Detail when this occurred and what happened.

* Have you ever attempted suicide?

Yes No

If Yes, please describe how, when and what were the triggers.

* Have you seen mental health professionals before? (Current and past psychotherapists and psychiatrists)

Yes No

If Yes, please specify dates, reason for counseling and your experience. Please provide email, FAX, tel info here

* Have you ever been hospitalized for a psychiatric issue ?

Yes No

If Yes, please describe, where, when and why? Please detail any medications you were prescribed and any other treatment received)

* Ever been in rehab for an addiction?

Yes No

If Yes, detail dates and situation

* Have you ever had a DUI ?

Yes No

If Yes, when?

* Have you ever been arrested?

Yes No

If yes, when and why?

What else would you like me to know?

Documents Upload

I understand that if I do not receive a response within 48 business hours I should alert the office at (310) 529-6051.

I have answered the above questions truthfully and completely.

* Type your full name

NOTE: AFTER YOU PRESS “SUBMIT” PLEASE CALL THE OFFICE AT 310-529-6051
AND LEAVE A VOICE MESSAGE TO
ALERT DR STEIN OF YOUR SUBMISSION