Cornerstone Psychiatric Services, Inc.
1790 E Venice Avenue Suite 204
Venice, FL 34292

 

Phone: (941) 488-8884

Fax: (941) 488-5554

Medical Records Fax:

(941) 375-0119

Monday - Thurs: 8am-5pm

 

Friday: 8am-12:00pm

 

Sat./Sun.: Closed

 

Notice:

  • We are closed for lunch from 12:00pm to 1:00pm
  • Office visits are by appointment only. We are not set up for emergencies or walk-in appointments.

Patient Forms

The following 3 forms are for you to review and keep for reference:

  1. Patient Rights and Responsibilities
  2. Notice of Privacy Practices
  3. Office Policies
Patient Rights and Responsibilities
Patient Rights and Responsibilities Form[...]
Adobe Acrobat document [17.6 KB]
HIPAA - Notice of Privacy
NoticeofPrivacy-v0318.pdf
Adobe Acrobat document [2.7 MB]
Cornerstone Psychiatric Office Policies
Office Policies-v0618.pdf
Adobe Acrobat document [93.6 KB]

Required Forms

Welcome Letter, Initial Visit Deposit requirement, Map/Directions to our facility and Checklist of what to do
Welcome to Cornerstone letter V06.2020.p[...]
Adobe Acrobat document [120.5 KB]

New Patient Registration Steps

1) Pay your Initial Visit Deposit of $60.00

2) Complete New Patient Registration Form (Online version recommended) or download Paper Form and Upload your documents using the Upload File feature.

Initial Visit Deposit

Before scheduling your first visit with us, we require a $60 initial visit deposit. This is to secure your appointment date and time with our office. See our Welcome Letter document for details on this deposit.

Online New Patient Registration Form

Preferred Method for submitting 

Paper Form

If you are not able to to complete the Online version then download New Patient Registration Form and write in your responses. Return your completed form to our office at least 2 days prior to your scheduled first appointment by using the Upload Document feature on our website, mail back to us or drop off at our office.

Upload Documents

Use this to send us documents such as:

* Paper form of Patient Registration Form

* Photo ID

* Insurance Cards (front & back sides)

* Medication List

* Lab results

* Medical Records from other providers

* other documents 

New Patient Registration form is required for all new patients and patients that have not been seen 3 or more years ago. Complete preferred method of the Online form -OR- you can download the 'Paper Form' and write in your responses.

 

Benefits of the Online Form: you have the ability to upload documents such as photo id, insurance card (front and back side), most recent lab results, medication list and other documents.  We also receive your information immediately after you submit your form. Please complete this as soon as possible but at least 2 days before your first appointment date. 

 

If you download the Paper Form, then return completed form to our office at least 2 days before your first appointment. Another option is stopping in our office before your appointment and picking up a copy of the new patient form.

 

Paper Form - New Patient Registration
Patient Registrationv0220.pdf
Adobe Acrobat document [267.9 KB]

You can also complete the Psychiatric Medication List form below for additional details on your past psychiatric medication history.

Additional Documents:

(Optional forms that you can complete or you may be asked by our staff to complete)

Psychiatric only Medication List
You can use this form for your list of Psychiatric related medications to add to your New Patient Registration form OR if you have been asked by the Cornerstone Psychiatric staff to complete this form.
Medication List - Psychiatric onlyx.pdf
Adobe Acrobat document [153.8 KB]
Complete Medication List
This document you can print and complete to provide us your complete list of medications, vitamins, herbal supplements and any other over-the-counter products.
Medication Complete List.pdf
Adobe Acrobat document [139.8 KB]
Patient Demographic Update Form
Download and complete this form if you have any any change of name, address, phone and/or insurance/financial responsibility. Mail back to our office or bring it in at your next appointment.
Patient Demographic Update Form v1119.pd[...]
Adobe Acrobat document [183.9 KB]
Controlled Substance Agreement
Required for new patients currently on a controlled substance (Schedule II, III, IV and V) and current patients that have been asked to complete this form.
Controlled Substance Contract Agreementv[...]
Adobe Acrobat document [98.5 KB]
Adult ADHD Self-Report Scale (ASRS v1.1)
Complete this form only if you have been asked to by Cornerstone Psychiatric OR if you have been diagnosed with Adult ADHD already, please complete this form and bring with you at your first appointment. The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist was developed in conjunction with the World Health Organization (WHO), and the Workgroup on Adult ADHD that included the following team of psychiatrists and researchers:
• Lenard Adler, MD, Associate Professor of Psychiatry and Neurology
New York University Medical School
• Ronald C. Kessler, PhD, Professor, Department of Health Care Policy
Harvard Medical School
• Thomas Spencer, MD, Associate Professor of Psychiatry
Harvard Medical School
ADHD-ASRSv1.1x.pdf
Adobe Acrobat document [545.3 KB]

DISCLAIMER: This screening tool is used to provide clinical support at the point of care. The questionnaire is meant to be completed by a patient to help facilitate communication with a care team in a medical office environment. It is not a diagnostic instrument and is to be used solely within the context of medical treatment with a physician/nurse practitioner or other health care provider.

Patient Health Questionnaire (PHQ-9)
If you have been asked by your clinician to complete this form, please print and complete this PHQ-9 form and bring it with you at your next appointment.
DISCLAIMER: This screening tool is used to provide clinical support at the point of care. The questionnaire is meant to be completed by a patient to help facilitate communication with a care team in a medical office environment. It is not a diagnostic instrument and is to be used solely within the context of medical treatment with a physician/nurse practitioner or other health care provider.
PHQ-9_CPS.pdf
Adobe Acrobat document [569.5 KB]
Generalized Anxiety Disorder Screener (GAD-7)
If you have been asked by your clinician or office staff to complete this form, please print and complete the GAD-7 screener tool form and bring it with you at your next appointment.
DISCLAIMER: This screening tool is used to provide clinical support at the point of care. The questionnaire is meant to be completed by a patient to help facilitate communication with a care team in a medical office environment. It is not a diagnostic instrument and is to be used solely within the context of medical treatment with a physician/nurse practitioner or other health care provider.
GAD7 Form.pdf
Adobe Acrobat document [324.0 KB]
Mood Disorder Questionnaire (MDQ)
If you have been asked by your clinician or office staff to complete this form, please print and complete the MDQ screener tool form and bring it with you at your next appointment.
DISCLAIMER: This screening tool is used to provide clinical support at the point of care. The questionnaire is meant to be completed by a patient to help facilitate communication with a care team in a medical office environment. It is not a diagnostic instrument and is to be used solely within the context of medical treatment with a physician/nurse practitioner or other health care provider.
MDQ.pdf
Adobe Acrobat document [491.1 KB]
Referral Form
If you are referring a patient to our practice, please complete this form and send along with the requested documents stated on the form. Thank you for your referral.
Referral Form.pdf
Adobe Acrobat document [133.7 KB]

** NEW ON-LINE VERSION **

Click Here

Authorization to Release of Information (ROI) FORM

 

 

 

OR

You can click on the pdf document version below,

print and hand write your responses.

Authorization to Release of Information (ROI)
Who needs to complete this form? See the reasons below:
1.) All new patients, we suggest and encourage you to complete this form for your Primary Care Physician (PCP) and your previous mental health provider(s). Please only one provider name per form. So, you will have to print multiple copies. Print additional copies to include your spouse or any individual(s) you allow to be able to call our office and ask/discuss information relating to your appointments, prescriptions and treatment.

2.) If you have recent lab order results from your PCP, please complete with your PCP contact information.

3.) If you have been asked by our office staff to complete this form.
Authorization to Release Information v11[...]
Adobe Acrobat document [68.5 KB]
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