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
Today M-D-Y
Are you looking for services for yourself or someone else?
* must provide value
I am looking for services for myself I am looking for services for another adult (over the age of 18) I am looking for services for a minor (under the age of 18)
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
Today M-D-Y
What is your relationship to the patient?
* must provide value
Mother Father Grandparent Guardian Other
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
Please specify Gender Identity
* must provide value
Patient's Date of Birth
* must provide value
Today M-D-Y (if you are the patient, please re-enter your date of birth here)
Patient's Age
(If you are 14 or younger, you must have a parent complete this form with you)
* must provide value
View equation
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
please include zip code
Do both parents share legal custody of the patient?
* must provide value
Yes
No
Other
If other, please explain:
What is the relationship status of the child's legal guardians?
* must provide value
Married Never married Divorced Separated Other
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.
Best Phone Number
* must provide value
By entering your phone number, you agree to be contacted by CTSA staff via phone. Prefer not to be contacted by phone? Type (999) 999-9999
Do you consent to CTSA leaving you a voicemail stating that we are calling from the University of Pennsylvania?
* must provide value
Yes
No
Best Email Address
* must provide value
By entering your email address, you agree to be contacted by CTSA staff via email. Prefer not to be contacted by email? Type noemail@donotuse.com
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
Insurance through an employee of University of Pennsylvania, University of Pennsylvania Health System, or Children's Hospital of Philadelphia Insurance through student affiliation with the University of Pennsylvania Other insurance (insurance is not provided by the University of Pennsylvania) Uninsured Aetna
Please specify the patient's current insurance plan.
* must provide value
University of Pennsylvania PennCare (Independence Blue Cross) Aetna POS II Aetna Student Health (for students of UPenn and Drexel ONLY) Other Magellan through University of Pennsylvania or Children's Hospital of Philadelphia
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
No
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
Today M-D-Y
Is this the patient's only form of insurance?
* must provide value
Yes
No
Is Aetna Student Health the patient's only insurance provider?
* must provide value
Yes
No
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.
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.
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.
Were you referred to the center via COBALT?
* must provide value
Yes
No
How did you hear about CTSA?
* must provide value
What is the primary concern that brings you to CTSA?
* must provide value
Does the patient have any of these concerns or diagnoses (check all that apply)
* must provide value
Other concerns or diagnoses (not listed above)
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?
* must provide value
Yes
No
Please list the medication names, dosage, and approximate date the patient started
* must provide value
Are you (or the person you are filling this form out for) motivated to participate in treatment?
* must provide value
Yes No Other
Motivation elaboration:
* must provide value
What forms of treatment are you interested in receiving?
If available in the future, would you be interested in internet-based therapy services?
Yes
No
Which services would you be interested in (select all that apply)?
Which treatment options you would be comfortable with?Please note that the prefered treatment option cannot be guranteed
* must provide value
Which treatment modality would you prefer if telehealth is available?
* must provide value
If available, would you be interested in group treatment options?
Yes
No
I acknowledge that if the patient is 14 years or older, they are required by Pennsylvania law to consent to their own treatment.
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
Please select the times when you and/or the patient are able to complete the phone screen.
* must provide value
Would you prefer to be contacted by email or phone?
* must provide value
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**