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 weeks.
After completing this questionnaire, our intake process starts with a phone screening. Wait time for an evaluation can be approximately 8-12 weeks. If it appears that the CTSA would be a good fit for you based on the evaluation, you would then be placed on our waitlist for treatment. Wait time to begin treatment is typically 8-12 weeks after completing the evaluation.
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
* 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
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 our first contact with you will be through email.
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 and UPHS 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 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 Personal Choice or Keystone Health Plan East through Children's Hospital of Philadelphia only Keystone Health Plan East through University of Pennsylvania or UPHS only
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
Please choose the type(s) of provider you are interested in. There are 3 types of therapists in our group, and the main differences are:
* must provide value
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 8-12 weeks after the initial evaluation.
Were you referred to the center via COBALT?
* must provide value
Yes
No
Were you referred to the center via the TEAM clinic?
* must provide value
Yes
No
How did you hear about CTSA?
* must provide value
Have you ever been in contact with the CTSA in the past?
Yes
No
If yes, please describe your previous contact (e.g. completed a new patient questionnaire, completed a phone screen, completed an evaluation, participated in treatment with ______, etc.) and approximate date/s of previous contact.
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
Are you interested in receiving treatment through CTSA's Intensive Outpatient Program (IOP) for Obsessive Compulsive Disorder (OCD)? The IOP for OCD includes 4 hours per day of treatment, 5 days a week, for 6 weeks.
Treatment includes individual sessions with a licensed psychologist, exposure coaching with an individual therapist, and group therapy.
You must be able to commit 4 hours per day for the duration of the 6 week IOP program sometime between the hours of 9am and 5pm.
If you are accepted into the program, you must be physically located in PA, NJ, or DE for the duration of each telehealth visit.
Our program accepts Quest and Aetna insurances only. We are not participating providers for any Medicare or Medicaid insurances. All other participants must pay out-of-pocket.
The out-of-pocket cost for the IOP is $1,000 per day. The total cost ($1,000 per day x5 days per week for 6 weeks) is $30,000.
If you are paying out-of-pocket and plan to seek reimbursement from your insurance carrier, you will be required to seek a pre-authorization before starting the treatment program. If you click "Yes" that you are interested in the IOP for OCD, you will be contacted by one of our staff to further discuss the program, costs, and enrollment.
* must provide value
Yes
No
What forms of treatment are you interested in receiving?
* must provide value
If available in the future, would you be interested in internet-based therapy services?
* must provide value
Yes
No
Which additional services would you be interested in (select all that apply)?
Which treatment options you would be comfortable with?
* must provide value
What treatment option would be your preference (please choose one)?
In person
Telehealth
If available, would you be interested in group treatment options?
* must provide value
Yes
No
Are you interested in being contacted about potential research studies?
* must provide value
Yes
No
Thank you for completing this screening questionnaire.
