FORMS

For patients of Dr. Mirza only:

1) Please review the Notice of Privacy Practices (NPP) 

This document is LouCouPsych's notice that provides a clear, user friendly explanation of your rights with respect to their personal health information and the privacy practices of LouCouPsych.

2) Please complete the one-to-two question Acknowledgement of Receipt of NPP

This form simply states that you have received or reviewed and have access to a copy of the NPP as listed above. This is a legal document and will become a part of your medical record.

3) Please complete the Consent to Treatment Form

This form simply states that you are consenting to treatment at LouCouPsych. This is a legal document and will become a part of your medical record.

4) Please complete the Payment Policy

This form states that you understand that LouCouPsych providers are out of network providers, do not participate with any insurance networks, and payment is due at the time of service. A Superbill can provided upon request. This is a legal document and will become part of your medical record.

5) Please complete the Consent to Treatment via Telepsychiatry 

This form states that you are consenting to treatment via telepsychiatry, a method of delivering psychiatric care via an electronic means, such as over an app on your phone, tablet, or video enabled computer. Telepsychiatry is useful if you are unable to come in for face to face appointments due to distance, vacation, or emergencies, for example. This is a legal document and will become a part of your medical record.

 

6) Please pay your deposit at this time.

The appointment deposit has come about due to people cancelling initial evaluations at the last minute, thereby blocking off my limited availability to help other people who would have been able to make that appointment, as there is usually over a month of a wait list. If the deposit is not paid before 3pm on the day before the appointment, the appointment is considered forfeit and open to others. 

7) Please complete the Patient Registration Form

 

8) Please complete the New Patient Intake Form 

This form is the general psychiatric intake form and will allow me to get to know you a bit better before coming in for the first visit so that we can have a more focused initial interview. This form should take about 15 minutes to complete, but must be completed prior to your appointment.

Please complete the specifically requested supplemental forms/rating scales below