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 THIER
TYPED NAME AND EMAIL ADDRESS

Pre-Consult Questionnaire - Potential Patient

DIRECTIONS: Before taking the time to complete this form, 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.

CURRENT FEE SCHEDULE (Rates Subject to Change):

• 90 min initial consultation: $650
• 45 min appointments: $425
• In-Office Lab Collection & Administration: $65
• Document Production (electronic): $0.35/page
• Document Production (paper): $0.45/page + postage
• 60 min hourly rate: $500 for : Tele-visit and Telephone consultations; Prior Authorizations and other Insurance- Related Documentation (prorated); Reports and Letters (prorated); Disability Evaluation Services (prorated); Insurance Evaluation Services (prorated); Evaluation of Records (prorated); Sessions that are 60 min or more
• Between-Visit Prescription Refills(requires 48 business hours’ notice): $20 for non-controlled; $40 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.

Demographic Information:

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

* Who is your primary care physician?

* 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 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.


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.

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.

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 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?


PAST HISTORY

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