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					                        Suncoast Psychiatric Medical Clinic, LLC
                         Psychiatric Consultation Questionnaire
Today's date: ____________________________

Your Name: ______________________________________________________________
                            (First)                 (Middle)             (Last)
Nickname or preferred name: ________________________________________________
(To help protect confidentiality, we utilize first names in the waiting room. Please do not take
this as a discourtesy. Please indicate if you have a preferred alternative name.)

Date of birth: ___________________________               Age: _________________________

Home Address: ___________________________________________________________

City: _______________________________ State: ______________Zip: ______________

Business/Billing Address (if different): ________________________________________

City ________________________________State: ______________Zip: ______________

Telephone: Home: _______________                         Work: _______________

              Cell: _________________                    Other: _______________

Telephone calls will always be discreet, but please indicate any additional restrictions that

you care to request:_________________________________________________________

Emergency Contact:_______________________________Phone:___________________

Chief concern: Please describe the main difficulty that led to you coming in to see us:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Referral: Who referred you to this clinic or suggested that you give us a call?

Name: ___________________________________________ Phone: _________________

How did this person explain how we might be of help to you? ________________________


_________________________________________________________________________




From whom or where do you get your medical care?

                                           Page 1 of 8
                     Suncoast Psychiatric Medical Clinic, LLC
                      Psychiatric Consultation Questionnaire
  Doctor/Clinic                        Phone       When       Do you want us to
                                                 (Years)    coordinate care with them?




Major Surgeries                                                      When (year)




Major Medical Problem                                                When (year)




Current NON-Psychiatric Medications:                   Dosage            How many
                                                                         times daily?




Any Known Medications Allergies:


Any vitamins or herbal remedies taken on a regular basis?




                                       Page 2 of 8
                       Suncoast Psychiatric Medical Clinic, LLC
                        Psychiatric Consultation Questionnaire

Please describe common major medical problems in your family:
Person/Relationship            Major Medical Problem


Any Medications Prescribed, but no   Any Medications Prescribed, but not taken:


Please describe any history of psychiatric or psychological treatment:
When              With whom                   Diagnosis/Purpose Outcome/Benefits




Please describe your experiences (if any) with psychiatric medications:
Medication               When (current?) Dosage           Times per day Beneficial?




Alcohol                                                                        Yes     No
Have you ever felt the need to cut down on your drinking?
Have you ever felt annoyed by criticism of your drinking?
Have you ever felt guilty about your drinking?
Have you ever taken a morning “eye-opener?”
Have you had any alcohol to drink within the last 24 hours?
Does anybody you care about feel like you have a problem with alcohol?
(i.e., spouse, good friend, employer, etc.)
Have you ever had any legal (e.g., DUI), occupational, relationship or
financial problems due to alcohol?
Please describe any experiences with the following substances:
                   Ever Used? Currently?          How much?            Desire to quit?
Tobacco
Caffeine
Cocaine
Marijuana
Ecstasy
Oxycoton, etc.
Other:




                                         Page 3 of 8
                         Suncoast Psychiatric Medical Clinic, LLC
                          Psychiatric Consultation Questionnaire
Psychiatric, emotional or substance abuse problems among any family members:
Family Member/Relationship      Problem                      Treatment Received/Beneficial?




Do you have any history of being abused? Yes ____________ No ______________
(If the answer is yes, do not attempt to write any thing more about the abuse here. This topic
will be addressed in person with the doctor.)

Are you currently:
Single (never married) _____Separated_____Married _____Divorced_____Widowed_____

If married: How many years _____________ What number (1st, 2nd, 3rd?) _____________

How would you describe your relationship with your spouse/significant ofther? _____

_________________________________________________________________________

Any recent major losses or deaths personally or in the family? ___________________

_________________________________________________________________________

_________________________________________________________________________

List children, if any:
Name                                             Age                Get along well?




Do you currently have any legal issues such as a lawsuit pending or contemplated?

No_________If yes, please briefly explain:______________________________________

_________________________________________________________________________

Is there anything else that is important for us to know about, and that you have not written
about? If yes, please tell me about it here or on another sheet of paper:

_________________________________________________________________________

_________________________________________________________________________




                                          Page 4 of 8
                      Suncoast Psychiatric Medical Clinic, LLC
                       Psychiatric Consultation Questionnaire
                             BRIEF MOOD SURVEY
INSTRUCTIONS: Put a check in the box after each item that most accurately describes how you
have been feeling during the past week, including today.




                                                                    SOMEWHAT
                                                       NOT AT ALL




                                                                               LY TRUE = 2




                                                                                                        LY TRUE = 4
                                                                               MODERATE




                                                                                                        COMPLETE
                                                       TRUE = 0


                                                                    TRUE = 1




                                                                                             TRUE = 3
                                                                                             VERY
                        DEPRESSION
1. I feel sad or down in the dumps.
2. I feel discouraged or hopeless.
3. I have low self-esteem.
4. I feel worthless or inadequate.
5. I have no pleasure or satisfaction in life.
                       TOTAL:
                       SUICIDAL URGES
1. I have had thoughts of suicide.
2. I would like to end my life.
                       TOTAL:
                       ANXIETY
1. I feel anxious much of the time.
2. I feel frightened much of the time.
3. I worry about things over and over.
4. I feel tense or on edge much of the time.
5. I feel nervous much of the time.
                       TOTAL:
                       ANGER
1. I feel frustrated much of the time.
2. I feel annoyed easily.
3. I feel resentful towards others.
4. I feel angry easily and/or often.
5. I am easily irritated.
                       TOTAL:
                           TOTAL OF ALL CATEGORIES:
 ANY OTHER SIGNIFICANT SYMPTOMS THAT YOU WOULD LIKE TO NOTE:




                                        Page 5 of 8
                             Suncoast Psychiatric Medical Clinic, LLC
                              Psychiatric Consultation Questionnaire
The following are the normal fees as of June 2006:
        Psychiatric Evaluation/Diagnostic Consultation (approximately 60 minutes)             $235.00
        Medication Follow-Up with Brief Therapy (approximately 25 minutes)                    $125.00
        Medication Follow-Up with Extensive Therapy (approximately 55 Minutes)                $235.00
        Brief phone call                                                                Complimentary
                (medication refill request, clarification of medication directions, etc.)
        Extended phone call                                                     As per above time-frames.
        Letters to attorneys, insurance companies, etc.                         As per above time-frames.
        Interactions with individuals other than the patient:                   As per above time-frames.
                (Authorized family members, attorney, etc.)


DECISION TO FOREGO MEDICAL MALPRACTICE:

Effective January 01, 2007, I have made the decision to stop participating in any formal medical
malpractice insurance. As required by law and in the interests of good faith notification of this
decision, the following statement is disclosed:

"Under Florida law, physicians are generally required to carry medical malpractice insurance or
otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. YOUR
DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is
permitted under Florida law subject to certain conditions. Florida law imposes penalties against
noninsured physicians who fail to satisfy adverse judgments arising from claims of medical
malpractice. This notice is provided pursuant to Florida law."

Florida regulations provides for a maximum limit of liability. I am requesting my patients to volitionally further
limit this imposed limit to $10,000 (ten thousand dollars) which is 1/10th (one tenth) of the regulatory-imposed
limit). In fairness to other patients who do accept this limit of liability, the limit will be considered a condition
of treatment. Individuals whom do not desire to participate in this limitation or determine that this decision is
not acceptable for any reason will be provided with assistance in obtaining treatment from another psychiatrist,
should they so desire that assistance.

Confidentiality is an inherently essential aspect of meaningful psychiatric treatment. Nonetheless, it is
occasionally important to allow family members or significant individuals others with the opportunity to
express and concerns and/or provide Dr. McClure with collateral information or concerns. Every effort
will be taken to respond to these situations in a manner that is maximally respectful of your privacy
within the confines of safe treatment. Any desired limitations to this authorized communication
(example: Dr. McClure to receive information but not provide any information other than confirmation
of my treatment by participation in the communication) should be noted below.

I agree to allow Dr. McClure to acknowledge my treatment and give and receive communications with
the following individual(s):
___________________________________               ________________________________________
         (name of individual)                            (limits of authorization, if any)
______________________________________            ____________________________________________
         (name of individual)                            (limits of authorization, if any)
___________________________                                ______________________________
        (name of individual)                                       (limits of authorization, if any)

                         FOR MEDICARE RECIPIENTS ONLY:
                          Private Contract – Medicare Opt-Out

                                                    Page 6 of 8
                               Suncoast Psychiatric Medical Clinic, LLC
                                Psychiatric Consultation Questionnaire
This agreement is between Dr. Michael McClure, M.D. Ph.D. ("Physician"), whose principal place of business is Suncoast
Psychiatric Medical Clinic, LLC, and patient ______________________________ ("Patient"), who resides at
______________________________________________________________ and is a Medicare Part B beneficiary seeking
services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Physician has
informed Patient that Physician has renewed his having opted out of the Medicare program effective on August 14, 2007 for
a period of at least two years, and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892
or any other section of the Social Security Act.
Physician agrees to provide the following medical services to Patient (the "Services"):

         Psychiatric diagnostic examination/evaluation, management of psychotropic (psychiatric)
         medications, individual psychotherapy, marital/couples therapy, brief phone calls, forensic
         (legal) evaluations and any other services typical to an outpatient general psychiatric office.

In exchange for the Services, the Patient agrees to make payments to Physician pursuant to the
Attached Fee Schedule. Patient also agrees, understands and expressly acknowledges the following:
        Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with
respect to the Services, even if covered by Medicare Part B.

        Patient is not currently in an emergency or urgent health care situation.

        Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations
apply to charges for the Services.

       Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because
payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny
reimbursement.

        Patient acknowledges that they have a right, as a Medicare beneficiary, to obtain Medicare-covered items and
services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter
into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have
not opted-out.

        Patient agrees to be responsible to make payment in full for the Services, and acknowledges that Physician will not
submit a Medicare claim for the Services and that no Medicare reimbursement will be provided.

        Patient understands that Medicare payment will not be made for any items or services furnished by the physician
that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were
submitted.

        Patient acknowledges that a copy of this contract has been made available to him.

      Patient agrees to reimburse Physician for any costs and reasonable attorneys’ fees that result from violation of this
Agreement by Patient or his beneficiaries.

Executed on ____________________ by __________________________________ and Dr. Michael McClure, M.D. Ph.D.
                [Date]                        [Patient’s Name]
_________________________________________________         _______________________________________________
                [Patient’s Signature]                                 Michael J. McClure, M.D., Ph.D.




    ACKNOWLEDGEMENT OF NOTIFICATION OF POLICIES AND AGREEMENT TO ABIDE BY
                              THOSE POLICIES




                                                         Page 7 of 8
                          Suncoast Psychiatric Medical Clinic, LLC
                           Psychiatric Consultation Questionnaire
I, the client (or person acting for the client), request that Suncoast Psychiatric Medical Clinic, LLC
provide psychiatric professional services to me or to the client in whose behalf I am responsible. I
acknowledge the following:
     1. I understand that I will be provided with a complete copy of this Psychiatric Consultation
         Questionnaire in its’ entirety, upon request.
     2. I agree to the limits of confidentiality provided above and authorize the breach of those limits
         to the individuals listed within limits so annotated.
     3. I understand that Suncoast Psychiatric Medical Clinic, LLC does NOT participate as an “in
         network” provider with any and all insurance providers that I may have. Moreover, Suncoast
         Psychiatric Medical Clinic, LLC does NOT directly submit insurance claims on the behalf of
         patients. As such, I am directly responsible for paying the fee for services rendered at the
         time of the rendering of such service.
     4. I understand that I may pursue reimbursement of said fees at my own discretion (other than
         any claims that could otherwise be made to Medicare, which are exempt from reimbursement).
         An invoice detailing all charges, diagnostic codes and other relevant information will be
         provided to me by Suncoast Psychiatric Medical Clinic, LLC for all payments rendered to
         facilitate any such reimbursement.
     5. I understand that payment is due in full at the time of services rendered and that failure to
         make appropriate payment at that time is grounds for termination of treatment and/or the
         charging of additional credit fees.
     6. I understand the notification provided in this document of the decision of Michael J. McClure,
         M.D., Ph.D. and Suncoast Psychiatric Medical Clinic, LLC to forego participation in any
         medical malpractice insurance.
     7. I voluntarily agree to limit any medical malpractice claims, should they arise, to a maximum of
                                                                                     th
         $10,000 (ten thousand dollars). I have been notified that this limit is 1/10 (one tenth) of the
         regulatory limit, but nevertheless agree to abide by this limit of my own volition.
     8. I understand that I have the right to NOT participate in any of the limits provided by the policies
         described within this document. However, such decision would also constitute the decision to
         not enter into treatment with Dr. McClure/ Suncoast Psychiatric Medical Clinic, LLC.
     9. I understand that should I not agree to these limits, or at some later time determine that these
         limits are no longer acceptable, I should notify Dr. McClure or his agent immediately. I
         understand that I will subsequently be provided with assistance in obtaining an alternative
         provider, should I desire and request that assistance.

__________________________________________________________                     _________________
                Signature of client (or person acting for client)                      Date

__________________________________________________________
                            Printed name

I, the psychiatrist, have discussed the issues above with the client (and/or the person acting for the
client). My observations of the person's behavior and responses give me no reason to believe that this
person is not fully competent to give informed and willing consent.
_________________________________________________________ ____________________
                          Michael J. McClure, M.D., Ph.D.                                   Date




                                               Page 8 of 8

				
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