Online New Patient Information

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Attention new clients

Please be advised that being seen in our practice does not guarantee the prescription of any specific medications, including but not limited to Benzodiazepines (e.g., Xanax, Klonopin, Valium, Ativan) or Adderall. The decision to prescribe such medications is solely at the discretion of your healthcare provider, based on their clinical assessment and your individual needs.

To provide you with the best care, we require new patients 18 years of age and older being seen for ADHD to undergo a Psychological Assessment & Evaluation. This helps us understand your unique needs and offer effective treatment.

You can choose any qualified provider for this assessment, but we recommend a local company aligned with our care approach. The choice is yours, and your well-being is our priority.

We’re here to support your journey to better mental health. Reach out if you have questions.

Coastal Bend Psychological Associates
4639 Corona Dr.
Ste. 34
Corpus Christi, TX 78411
(361) 442-4024 office

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New Patient Information Form - Step 1 of 4

Is the patient 18 years of age or older and seeking treatment for ADHD? *

Have you had a Psychological Assessment & Evaluation done in the last 3 years? *

Please upload a copy of your Psychological Assessment & Evaluation

Click or drag a file to this area to upload.

If you are unable to upload the requested information, please bring it with you to your office visit.

To provide you with the best care, we require new patients 18 years of age and older being seen for ADHD to undergo a Psychological Assessment & Evaluation before being seen by our office.

After receiving your Psychological Assessment & Evaluation, make sure to upload a copy of your report when completing the online new patient information packet or bring it with you on your first office visit.

This helps us understand your unique needs and offer effective treatment. You can choose any qualified provider for this assessment, but we recommend a local company aligned with our care approach. The choice is yours, and your well-being is our priority.

Coastal Bend Psychological Associates 
4639 Corona Dr. Ste. 34 
Corpus Christi, TX 78411 
(361) 442-4024 office

DEMOGRAPHICS - PATIENT INFORMATION

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

What clinic location would you like to visit? *

Date of Birth: *

Social Security *

Gender *

Male
Female

Home Phone *

Work Phone

Cell Phone *

Email *

Is the patient a minor? *

Complete the following information if the patient is a minor

If the parents are divorced, indicate which parent has the right to determine medical care.

Mother's Name *

Father's Name *

Legal Guardian's Name *

Relationship to minor *

If parents are divorced, which parent has the right to determine medical care? *

Mother
Father
Parents are not divorced

GUARANTOR INFORMATION (Individual responsible for payment)

Is the patient the Guarantor? *

Guarantor Name *

First

Middle

Last

Relationship to patient *

Parent
Legal Guardian
Spouse
Other

If relationship to patient is "other", please explain...

Guarantor Address *

Address Line 1

Address Line 2

City

State

Zip Code

EMERGENCY CONTACTS

Emergency Contact #1 Name *

First

Last

Emergency Contact #1 Phone *

Relationship to patient *

Parent
Legal Guardian
Spouse
Other

If relationship to patient is "other", please explain...

Emergency Contact #2 Name

First

Last

Emergency Contact #2 Phone

Relationship to patient

Parent
Legal Guardian
Spouse
Other

If relationship to patient is "other", please explain...

PROFESSIONAL REFERRAL

Name

First

Last

Professional Title

Phone

Insurance Information

Medicare? *

Medicaid? *

TriCare? *

Star Plus? *

Other? *

Insurance Company *

Phone *

Plan *

Member ID *

Group Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please upload a photo or digital scan of your insurance card(s)below...

Click or drag files to this area to upload. You can upload up to 3 files.

If you are unable to upload the requested information, please bring it with you to your office visit.

Please upload a photo or digital scan of your drivers license below...

Click or drag files to this area to upload. You can upload up to 2 files.

If you are unable to upload the requested information, please bring it with you to your office visit.

FINANCIAL RESPONSIBILITY

Signature *

Date *

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PURPOSE OF VISIT - Important! Please provide this information in the space below

Please tell us why you are here *

Additional Information

Sleep (hours per night) *

Do you experience any of the following? *

Nightmares
Onset Insomnia
Middle Insomnia
Early Insomnia
N/A

Please check all that apply *

Sadness
Fatigue
Withdrawal / Decreased Socialization
Thoughts of Hurting Self
Racing Thoughts
Irritability
Anxiety
Attention Deficit Hyperactivity
Behavorial Problems
Impulsivity
Unpredictable Dangerous Behavior
General Overwhelming Stress
Hallucinations
Anything you feel is important
N/A

List any drugs that you are currently using or have used in the past 3 years: *

--NONE--
Marijuana (cannabis)
Synthetic cannabinoids (K2, Spice)
Cocaine
Methamphetamine
MDMA (Ecstasy)
LSD
Psilocybin (Magic Mushrooms)
Hallucinogenic research chemicals
Ketamine
PCP (Phencyclidine)
GHB (Gamma-Hydroxybutyrate)
Designer drugs (e.g., synthetic cathinones, synthetic opioids)
Bath salts
Inhalants (e.g., paint thinner, aerosols)
Anabolic steroids (when used without a prescription)
Prescription opioids used without a prescription
Other prescription medications not prescribed to the patient
Other (provide details in the comment box below...)

Please remember that it's essential to be honest with your healthcare provider to ensure safe and effective medical care.

Other illitic drug use not listed above: *

PSYCHIATRIC HISTORY

Have you ever seen a specialist/psychiatrist? *

If yes, please fill out the information below.

1. Name of Physician / Clinic *

Duration of Treatment *

Location (City / State) *

Reason for Treatment *

2. Name of Physician / Clinic

Duration of Treatment

Location (City / State)

Reason for Treatment

3. Name of Physician / Clinic

Duration of Treatment

Location (City / State)

Reason for Treatment

Have you ever seen a primary care doctor for mood issues? *

If so, please explain when and for what reason? *

Have you ever been hospitalized in a psychiatric facility? *

If so, please fill out the information below.

1. Name of Physician / Clinic

Duration of Treatment

Location (City / State)

Reason for Treatment

2. Name of Physician / Clinic

Duration of Treatment

Location (City / State)

Reason for Treatment

CURRENT MEDICATIONS

Pharmacy *

Drug Allergies? *

What reaction do you have? *

Please list any medications that you are now taking. Include non-prescription medications and vitamins or supplements: *

Helpful Information

Place of Birth

Where Raised?

Family Structure

Two Parent Family

If no, please explain

Siblings

1/2 Siblings

Step Siblings

Education

Highest Grade

Other Education

Degrees/Certifications

Employment History

Occupation

Disabled

Year

Reason for Disability

Cultural and Religious Considerations

Cultural Identification

Anglo
Hispanic
Black
Other

Religious Preference

Sexual Indentification

Heterosexual
Undeclared
Homosexual
Bisexual
Transgender

Marital Status

Single
Married
Divorced
Widowed

Number of Marriages

Number of Significant Relationships

Number of Children

Legal

Any Arrest Convictions

If Yes, please explain

Living Situation

Family Composition

Military

Military Service

Branch of Service and number of years served

History of Symptoms

Family History of Mental Illness

Negative
Positive
Unavailable

Mother's Side

Father's Side

Abuse/Assault

As a Child?

As an Adult?

Trauma Stress Disorders

PTSD

If Yes, please provide

ADHD

If Yes, please provide

Autism

Pervasive Developmental Diagnoses

Anger Problems

Frequency

Age of Onset

Violent Behavior

Anger problems caused by

Educational
Social Situations
Occupational
Marital
Legal

Oppositional Defiant Problems

If Yes, please explain

Anxiety

Age of Onset

Triggers/Participating Factor(s)

Episodes per week, month, year

Treatment

Last Episode

Depression

Age of Onset

Triggers/Participating Factor(s)

Episodes per week, month, year

Treatment

Memory Problems

If Yes, check all that apply

Recent memory
Long-term memory
Forgetful
Missed appointments
Forget to pay bills

Bipolar Disorder

Age of Onset of Symptoms

Precipitating Factor(s)

Episodes per week, month, year

BP/Mania

BP Depression

Eating Issues

Age of Onset of Symptoms

Episodes

Treatment

Obsessive Compulsive Thoughts or Actions

Age of Onset of Symptoms

Episodes

Treatment

Hallucinations or Delusions

Age of Onset

Symptoms

Treatment

History of Chemical Use

Have you ever...

Used Nicotine

Smoked and/or Vaped?

If Yes, please explain

Used Alcohol

If Yes, please explain

Used recreational drugs

If Yes, please explain

Please select

Marijuana
Cocaine
Methamphetamine
Heroin
Other, i.e. prescription drugs
LSD; PCP, Whip; Synthetic Marijuana; inhalant etc

Do you receive Methadone

Do you receive Suboxone

XANAX AND ADDERALL POLICY

I understand that Psychiatric Specialists of Texas does not routinely prescribe Benzodiazepines. For example, but not limited to: Xanax, Klonopin, Valium, or Ativan.
This office also does not routinely prescribe Adderall.
I also understand that being seen in this practice does not mean I will get any of the above mentioned medications. It is at the prescriber's sole discretion if they are prescribed.
If a benzodiazepine medication is prescribed and dosage is not taken as prescribed, there will be no additional prescriptions called in early to the pharmacy.
By placing my name below in the signature, I understand and agree with all conditions listed in the previous statement.

Electronic Signature Agreement:
I, the undersigned, agree and understand that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian.

Electronic Signature *

First

Last

Date *

Please complete the following forms if applicable:

Non-Custodial Parent Form (If it is child under 18 and you share custody of the child)
Teachers Evaluation Form if you suspect your child has Hyperactivity of Inattentive Disorder)
Controlled Substance Contract if you are taking or think you will be prescribed a controlled substance.

Is there anything else we should know about you?

Phone

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If you have any questions call us on (361) 452-1151