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IwLLzvpTgnygRYQ6QeKpuiTnF7bABCTeWfIobfHskWPNeAWURp92rt3I46AoeqDa5mjtM9Jc5TuPCh7ZXvoAd5xo9WJGGegPZSp5LbcGbKPfZzMI2eagbmSx

CTSA New Patient Screening Questionnaire

Thank you for your interest in the CTSA. We offer diagnostic evaluation and outpatient treatment for obsessive compulsive disorder, posttraumatic stress disorder, and anxiety-related disorders. In order to be sure that we will be a good fit for treatment at our specialty clinic, we ask that you answer the following questions to the best of your ability. Once we have received your responses, we will be in touch to schedule an initial in-person evaluation or to provide you with appropriate referrals.

This questionnaire is hosted on a confidential server. The security of your information is of great importance to us.

**Please note that completion of this questionnaire is a prerequisite to being accepted as a new patient and does not guarantee that CTSA will provide therapy services for you or your child.**

Thank you!

If you feel that you are a danger to yourself or to others, please immediately discontinue this screening tool and call 911 or go to your nearest emergency room. If you are struggling with suicidal thoughts or feelings, you can contact the National Suicide Prevention Lifeline (which provides 24/7, free, confidential support) at 1-800-273-TALK (8255) or the Pennsylvania Hospital Crisis Response Center at 215-829-5433. Because CTSA is a small outpatient specialty clinic and our staff is not on call, we are unable to provide emergency/crisis services. Information entered into this questionnaire is typically reviewed in the next 3-4 business days.

**YOU MUST CLICK SUBMIT AT THE END OF THIS QUESTIONNAIRE OR YOUR RESPONSES WILL NOT BE RECORDED**

After completing this questionnaire, our intake process starts with a phone screening.

If it appears that the CTSA would be a good fit based on the phone screening, you would then be scheduled for or placed on our waitlist for a full evaluation, depending on availability at the time. Wait time for an evaluation can be approximately 3-4 months.

After the evaluation, if you and the clinician completing your evaluation deem our center to be a good fit for treating your symptoms, there is typically a 3-4 month wait to begin treatment. Note that if you require after-school hours, your wait time can be significantly longer.

Please remember that the CTSA is open Mondays - Fridays, 9 am to 5 pm. All appointments for phone screenings, evaluations, and treatment are scheduled within those times.

Most evaluations and treatment are currently being conducted via telehealth. Because of telehealth regulations, we can only see individuals who reside in Pennsylvania, New Jersey, and Delaware at this time.

Date of Inquiry

* must provide value

M-D-Y

Are you looking for services for yourself or someone else?

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First name of person filling out this form

* must provide value

Last name of person filling out this form

* must provide value

Date of Birth of person filling out this form

* must provide value

M-D-Y

What is your relationship to the patient?

* must provide value

Other relationship:

* must provide value

Patient's name

* must provide value

Patient's Gender Identity

* must provide value

Male

Female

Transgender

Something else

Prefer not to disclose

Gender Non-Conforming / Genderqueer

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Please specify Gender Identity

* must provide value

Patient's Date of Birth

* must provide value

M-D-Y

Patient's Age
(If you are 14 or younger, you must have a parent complete this form with you)

* must provide value

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In the state of Pennsylvania, adolescents ages 14-18 can consent to outpatient mental health examination and treatment for him/herself without parental consent. Parents can also consent on behalf of the adolescent, without the adolescent's consent. Neither the parent nor the adolescent may override the other's consent. (Age of Consent to Mental Health Treatment in Pennsylvania Effects of Act No. 2004-147; Senate Bill No. 137, Session of 2004). Therefore, either a parent or adolescent (14+) can initiate the treatment process. Consent for evaluation/treatment from one or both parties (parents or teen) will be collected before the evaluation.

Patient's address

* must provide value

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Do both parents share legal custody of the patient?

* must provide value

Yes

Other

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If other, please explain:

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What is the relationship status of the child's legal guardians?

* must provide value

Please specify relationship status:

* must provide value

I acknowledge that if two unmarried parents share legal custody, CTSA requires consent from both parents before starting treatment.

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Best Phone Number

* must provide value

Do you consent to CTSA leaving you a voicemail stating that we are calling from the University of Pennsylvania?

* must provide value

Yes

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Best Email Address

* must provide value

Please note that if you do not input an email address and/or phone number, we will be unable to follow up on this questionnaire and you will not be contacted by CTSA.

CTSA currently only accepts the following types of insurance:

Insurances offered through Penn Care PPO for University of Pennsylvania Health System employees only
Insurances offered for Children's Hospital of Philadelphia employees only through Personal Choice and Keystone Health Plan East
Insurances offered for University of Pennsylvania employees only through Keystone Health Plan East
All Aetna insurance plans (except Aetna Medicare)

We are not participating providers for any other insurance plans (including Medicare or Medicaid).

Before completing an evaluation or beginning treatment at the CTSA, all prospective patients should verify coverage and out-of-pocket cost with your insurance carrier as copays and deductible amounts will affect the total cost.

To verify your out-of-pocket cost, call your insurance company and provide the following information:

· Tax ID: 232743545

·       NPI: 1821486846

·       Evaluation Procedural Code: 90791

·       Follow-up Procedural Code: 90837

If you have any other insurance, you will need to pay out of pocket for services. Because the CTSA is an out-of-network provider for all other insurance plans, it is the patient's responsibility to get information from their insurance company about the possibility of reimbursement, the rate of reimbursement, and to submit claims on their own behalf for reimbursement. Please note that reimbursement is often only available through insurance companies for licensed psychologists, so if you decide to move forward with a postdoctoral fellow or student provider, all costs will be out of pocket

Before completing an evaluation or beginning treatment at the CTSA, you should verify your out-of-pocket cost and reimbursement rate with your insurance carrier.

To verify your out-of-pocket cost, call your insurance company and provide the following information:

· Tax ID: 232743545

·       NPI: 1821486846

·       Evaluation Procedural Code: 90791

·       Follow-up Procedural Code: 90837

What type of insurance does the patient have?

* must provide value

Please specify the patient's current insurance plan.

* must provide value

If other, please specify

* must provide value

What is the ID number on the patient's insurance card?

* must provide value

Is the patient the subscriber?

* must provide value

Yes

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Please enter the first and last name of the subscriber and the patient's relationship to them.

* must provide value

Please enter the subscriber's date of birth.

* must provide value

M-D-Y

Is this the patient's only form of insurance?

* must provide value

Yes

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Is Aetna Student Health the patient's only insurance provider?

* must provide value

Yes

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Please list other active insurance plans and which plan the patient has had longest.

* must provide value

Please specify the patient's insurance plan.

* must provide value

There are 3 types of therapists in our group:
-Licensed Psychologists ($600/initial evaluation; $500/90-minute therapy session; $250/50-minute therapy session)
-Postdoctoral Fellows ($400/initial evaluation; $350/90-minute therapy session; $175/50-minute therapy session)
-Doctoral Student (Masters-Level) Clinicians ($100/initial evaluation; $100/90-minute therapy session; $50/50-minute therapy session) *Please note: Doctoral Student Clinicians typically only see patients 18 years of age or older*

The main differences are:
1) the level of certification of the provider (important mainly for insurance reimbursement)
2) the cost (per hour) of services.

All of our therapists have specialty training in Cognitive Behavioral Therapy and experience in providing state-of-the-art treatment for OCD, PTSD, Trichotillomania, Anxiety and related disorders in children, adolescents, and adults. All would provide evidence-based treatment that is specific to the presenting concerns. Our Doctoral Student Clinicians have extensive training and are closely supervised by licensed psychologists. We are confident that all of our therapists would provide excellent treatment.

Licensed Psychologists ($600/initial evaluation; $500/90-minute therapy session; $250/50-minute therapy session)

Postdoctoral Fellows ($400/initial evaluation; $350/90-minute therapy session; $175/50-minute therapy session)

Doctoral Student (Masters-Level) Clinicians ($100/initial evaluation; $100/90-minute therapy session; $50/50-minute therapy session)

The provider with the soonest availability

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I acknowledge that the clinical hours of CTSA are 9:00 am to 5:00 pm Monday - Friday, and that treatment sessions take place within those hours.

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I acknowledge that, following the evaluation, there is a waitlist to begin treatment. The length of the waitlist depends on: 1) your flexibility in terms of days/times for appointments, and 2) the provider or level of provider best suited to provide treatment, which is based on your preferences, therapist/client availability, and clinical judgment about best fit based during the evaluation. At present, our estimate of wait times is 4-6 weeks after the initial evaluation.

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Were you referred to the center via COBALT?

* must provide value

Yes

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How did you hear about CTSA?

* must provide value

Online

Another mental health professional

Word of mouth

Flyer

Past patient

Don't know

What is the primary concern that brings you to CTSA?

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Does the patient have any of these concerns or diagnoses (check all that apply)

* must provide value

Attentional difficulties or Attention Deficit/Hyperactivity Disorder (ADHD)

Autism Spectrum Disorder (ASD) or Developmental Disability

Avoidant/Restrictive Food Intake Disorder (ARFID) or Picky Eating

Excoriation Disorder or Skin Picking

General Anxiety or Generalized Anxiety Disorder (GAD)

Mood Concerns (such as Depression or Bipolar Disorder)

Obsessive Compulsive Disorder (OCD)

Defiant Behavior or Oppositional Defiant Disorder (ODD)

Panic Attacks or Panic Disorder

Posttraumatic Stress Disorder (PTSD)

Selective Mutism

Separation Anxiety

Specific Phobia

Social Anxiety or Social Phobia

Tics

Tourette's Syndrome

Trichotillomania or Hair Pulling

Sleep-Related Issues or Disorders

Substace Use Related Difficulties

Eating Disorder (anorexia, bulimia, binge-eating)

Psychosis-Related Difficulties

Other

Other concerns or diagnoses (not listed above)

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If the patient has any formal diagnoses, please list them with the name of the doctor who made the diagnosis and the approximate date of diagnosis.

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Is the patient taking any medications?

* must provide value

Yes

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Please list the medication names, dosage, and approximate date the patient started

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Are you (or the person you are filling this form out for) motivated to participate in treatment?

* must provide value

Motivation elaboration:

* must provide value

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What forms of treatment are you interested in receiving?

Standard outpatient (1-2 sessions per week)

Intensive outpatient (daily session for 3.5 weeks)

If available in the future, would you be interested in internet-based therapy services?

Yes

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Which services would you be interested in (select all that apply)?

Self-guided web program

Therapist assisted web program

Mobile application

Which treatment options you would be comfortable with?

Please note that the prefered treatment option cannot be guranteed

* must provide value

In Person

Telehealth

Which treatment modality would you prefer if telehealth is available?

* must provide value

Telephone

Video

If available, would you be interested in group treatment options?

Yes

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* must provide value

I acknowledge that if the patient is 14 years or older, they are required by Pennsylvania law to consent to their own treatment.

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Thank you for completing this screening questionnaire.
When you have finished answering all questions, please be sure to select "Submit" below in order to save your responses and have them submitted for review by the CTSA intake team.

If you have not answered all required questions, you will be prompted to finish the questionnaire. Please note that unfinished questionnaires can not be reviewed.

In 3-4 business days after you submit the questionnaire (depending on your availability), you will receive a call from an intake coordinator at CTSA to complete a 10-15 minute phone screen. The phone screen must be completed before an evaluation appointment can be scheduled. If the patient is 18 years of age or older, they must be present at the time of the phone screen. From the questions below, please select days and times that you are available for us to contact you and/or the patient to complete the phone screen.

Please select the days when you and/or the patient are available to complete the phone screen.

* must provide value

Monday

Tuesday

Wednesday

Thursday

Friday

Please select the times when you and/or the patient are able to complete the phone screen.

* must provide value

9 am - 11 am

11 am - 1 pm

1 pm - 3 pm

3 pm - 4 pm

Would you prefer to be contacted by email or phone?

* must provide value

Phone

Please note specific requests with regard to the time of the phone screen (if any).

*We may not be able to accommodate all requests.*

**YOU MUST CLICK SUBMIT OR YOUR RESPONSES WILL NOT BE RECORDED**

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.