CTSA New Patient Screening Questionnaire

Are you looking for services for yourself or someone else?

First name of person filling out this form

Last name of person filling out this form

Date of Birth of person filling out this form

What is your relationship to the patient?

Other relationship:

Patient's name

Please specify Gender Identity

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

Do both parents share legal custody of the patient?

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

Please specify relationship status:

Best Phone Number

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

Best Email Address

What type of insurance does the patient have?

Please specify the patient's current insurance plan.

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

Is the patient the subscriber?

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

Please enter the subscriber's date of birth.

Is this the patient's only form of insurance?

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

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

Please specify the patient's insurance plan.

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.

Were you referred to the center via COBALT?

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

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.

Is the patient taking any medications?

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

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

Motivation elaboration:

What forms of treatment are you interested in receiving?

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

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

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

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

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

Would you prefer to be contacted by email or 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**