Patient Forms
The following forms are for you to review and keep for reference:
- Patient Rights and Responsibilities
- Notice of Privacy Practices
- Office Policies
Patient Rights and Responsibilities
Patient Rights and Responsibilities Form[...]
Adobe Acrobat document [17.6 KB]
Patient Rights and Responsibilities Form[...]
Adobe Acrobat document [17.6 KB]
*** Required Forms ***
Welcome Letter, Initial Visit Deposit requirement, Map/Directions to our facility and Checklist of what to do
Welcome to Cornerstone letter V11.19.pdf
Adobe Acrobat document [136.3 KB]
Welcome to Cornerstone letter V11.19.pdf
Adobe Acrobat document [136.3 KB]
New Patient Registration Form
IMPORTANT NOTICE: You must first make an Initial Visit Deposit of $60.00 before we can schedule your initial visit. Please read the WELCOME LETTER document above for complete details.
This New Patient Registration form is required for all new patients and patients that have not been seen 3 or more years ago. Print the form and write in your responses. Return completed form to our office before your appointment. If you have difficulty printing this form, we kindly ask that you arrive at least 20 minutes before your scheduled appointment so you can complete the form in our office lobby. Another option is stopping in our office before your appointment and picking up a copy of the new patient form.
Patient Registrationv0220.pdf
Adobe Acrobat document [267.9 KB]
IMPORTANT NOTICE: You must first make an Initial Visit Deposit of $60.00 before we can schedule your initial visit. Please read the WELCOME LETTER document above for complete details.
This New Patient Registration form is required for all new patients and patients that have not been seen 3 or more years ago. Print the form and write in your responses. Return completed form to our office before your appointment. If you have difficulty printing this form, we kindly ask that you arrive at least 20 minutes before your scheduled appointment so you can complete the form in our office lobby. Another option is stopping in our office before your appointment and picking up a copy of the new patient form.
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]
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]
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]
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]
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.
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.
adhd-questionnaire-ASRS111-selfreport.pd[...]
Adobe Acrobat document [58.1 KB]
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.
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.
adhd-questionnaire-ASRS111-selfreport.pd[...]
Adobe Acrobat document [58.1 KB]
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]
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]
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]
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]
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]
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]
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]
Print 