Start My Care Form - Five Minutes to Complete

AddressZen Integration

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Step 1 of 9 - Enter your basic information

I was referred to Televero Health by*
Select the ARC location*
Select the Covenant location*
Select The Children's Clinic location*
Other referring doctor's name*
Name of your Doctor who referred you to us:*
Reason for visit*
Have you been rereferred to us for care related to bariatric surgery?*

Yes

No

Do you want to submit appointments to insurance or pay out of pocket using your HSA, FSA, cash, or credit card to pay?*

Insurance

No insurance - Out of Pocket (HSA,FSA, Cash, Credit Card)
Upload photos of government issued drivers license/ ID card - Front*
Upload photos of government issued drivers license/ ID card - Back*
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Upload photos of insurance card - Front*
Upload photos of insurance card - Back*
Name of your insurance provider*
Name of your insurance provider (Other)*
e.g. Blue Cross Blue Shield, Aetna, United, Tricare, Humana, etc.
Your Insurance Provider Subscriber ID*
This can be found on your insurance card - It might also be called "Member ID"
Insurance Policy Effective Date:*
Month
Day
Year

Insurance Policy Holder's Name*
First Last
Insurance Policy Holder's Date of Birth*
Month
Day
Year

All files must be uploaded in jpg or png format.
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Tip: If your photo file size is too large and exceeds the limit, you can take a screen capture of your photo and instead upload the screen capture.

Emergency Contact Name*
First Last
Relationship to patient*
Emergency Contact Number*

The next 3 pages contain 21 easy questions that will provide us insights into your current well-being.
Please answer the questions the best that you are able to.
Over the last 2 weeks, how often have you been bothered by the following problems?
Are you feeling nervous, anxious, or on edge*

Not at all

Several days

More than half the days

Nearly every day
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*Are you feeling nervous, anxious, or on edge*
Not being able to stop or control worrying*

Not at all

Several days

More than half the days

Nearly every day
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*Not being able to stop or control worrying*
Worrying too much about different things*

Not at all

Several days

More than half the days

Nearly every day
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*Worrying too much about different things*
Trouble relaxing*

Not at all

Several days

More than half the days

Nearly every day
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*Trouble relaxing*
Being so restless that it is hard to sit still*

Not at all

Several days

More than half the days

Nearly every day
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*Being so restless that it is hard to sit still*
Becoming easily annoyed or irritable*

Not at all

Several days

More than half the days

Nearly every day
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*Becoming easily annoyed or irritable*
Feeling afraid as if something awful might happen*

Not at all

Several days

More than half the days

Nearly every day
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*Feeling afraid as if something awful might happen*
Are you currently or have you ever experienced repeated or unexpected “panic attacks” during which you suddenly are overcome by intense fear or discomfort for no apparent reason?*

No

Yes
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*Are you currently or have you ever experienced repeated or unexpected “panic attacks” during which you suddenly are overcome by intense fear or discomfort for no apparent reason?*

Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things*

Not at all

Several days

More than half the days

Nearly every day
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*Little interest or pleasure in doing things
Feeling down, depressed or hopeless*

Not at all

Several days

More than half the days

Nearly every day
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*Feeling down, depressed or hopeless
Trouble falling asleep, staying asleep, or sleeping too much*

Not at all

Several days

More than half the days

Nearly every day
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*Trouble falling asleep, staying asleep, or sleeping too much
Feeling tired or having little energy*

Not at all

Several days

More than half the days

Nearly every day
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*Feeling tired or having little energy
Poor appetite or overeating*

Not at all

Several days

More than half the days

Nearly every day
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*Poor appetite or overeating
Feeling bad about yourself - or that you’re a failure or have let yourself or your family down*

Not at all

Several days

More than half the days

Nearly every day
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*Feeling bad about yourself - or that you’re a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television*

Not at all

Several days

More than half the days

Nearly every day
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*Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual*

Not at all

Several days

More than half the days

Nearly every day
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*Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way*

Not at all

Several days

More than half the days

Nearly every day
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*Thoughts that you would be better off dead or of hurting yourself in some way

Over the last 2 weeks, have you experienced any of the following?
Any serious conflict with anyone or have you been thinking about hitting, threatening or hurting anyone?*

No

Yes
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*Any serious conflict with anyone or have you been thinking about hitting, threatening or hurting anyone?
Hearing voices telling you or commanding you to hurt or kill anyone?*

No

Yes
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*Hearing voices telling you or commanding you to hurt or kill anyone?
Wished or made plans to hurt or kill a specific person, hurt or kill a specific group of people, or chosen a place or location where you wanted to do damage?*

No

Yes
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*Wished or made plans to hurt or kill a specific person, hurt or kill a specific group of people, or chosen a place or location where you wanted to do damage?
Over the last two weeks have you consumed any alcohol, non-prescription drugs, or supplements?*

No

Yes
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*Over the last two weeks have you consumed any alcohol, non-prescription drugs, or supplements?*
How difficult have any of these problems made it for you to do your work, take care of things at home, or get along with other people?*

Not Difficult at All

Somewhat Difficult

Very Difficult

Extremely Difficult
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*How difficult have any of these problems made it for you to do your work, take care of things at home, or get along with other people?*
OCD Questions
Do you have any frequent thoughts, urges, or images that you do not want to have?*

No

Yes
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*Do you have any frequent thoughts, urges, or images that you do not want to have?*
Do you have any repetitive behaviors?*

No

Yes
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*Do you have any repetitive behaviors?*
Over the last month, have these obsessive thoughts and/or compulsive behaviors resulted in noticeable distress or interfered with your functioning at home, work, school, socially, in your relationships, or in any other significant manner that has consumed more than an hour of your time daily?*

No

Yes
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*Over the last month, have these obsessive thoughts and/or compulsive behaviors resulted in noticeable distress or interfered with your functioning at home, work, school, socially, in your relationships, or in any other significant manner that has consumed more than an hour of your time daily?*
Have you ever attempted suicide?*

No

Yes
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*Have you ever attempted suicide?*
Have you ever been to the emergency room for mental health or behavioral health care of any kind?*

No

Yes
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*Have you ever been to the emergency room for mental health or behavioral health care of any kind?*
Have you ever been psychiatrically hospitalized?*

No

Yes
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*Have you ever been psychiatrically hospitalized?*
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Triage Low Risk*

Low Risk - No Triage Outreach | Standard Appointment
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Triage Moderate Risk*

Moderate Risk - Triage Internal Communications, Accelerated Appointment Review | Discuss with Provider
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Triage Acute Risk*

Acute Risk - Triage Outreach, Urgent Appointment | Assess with VASA and Need for Wellness Check
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Triage Low*

Low
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Triage Moderate*

Moderate
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Triage Acute*

Acute
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Depression - Possible Harm to Self*

Depression - Possible Harm to Self
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Anxiety/Panic - Possible Harm to Self*

Anxiety/Panic - Possible Harm to Self
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Harm/Violence - Possible to others*

Harm/Violence - Possible to others
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Substance Abuse - Possible*

Substance Abuse - Possible
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GAD-7 Overall Score
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GAD-7 SI Positive Score
GAD-7 SI: Positive
GAD-7 SI: Negative
GAD-7 SI Positive*

GAD-7 SI Indicator: Yes
GAD-7 SI Negative*

GAD-7 SI Indicator: No
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PHQ-9 Overall Score
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PHQ-9 SI Positive Score
PHQ-9 SI: Positive
PHQ-9 SI: Negative
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PHQ-9 SI Positive*

PHQ-9 SI Indicator: Yes
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PHQ-9 SI Negative*

PHQ-9 SI Indicator: No
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VASA-Brief-Score
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OCD-Overall-Score

Medical Records Release Consent*
I consent to allow my referring doctor ("Referring Physician") to release confidential information and a copy of all my medical records, lab tests, or medication history, or a summary or narrative of my protected health information, to U.S. Televero Health, P.A. This information may be used or disclosed in connection with mental health and behavioral health treatment, payment, or healthcare operations.
Authorization for Disclosure of Treatment Information*
I consent to allow my U.S. Televero Health, P.A. Provider ("Televero Health Provider") to release confidential information and a copy of all my treatment history, medical records, lab tests, or medication history, or a summary or narrative of my protected health information, to my Referring Physician This information may be used or disclosed in connection with mental health and behavioral health treatment, payment, or healthcare operations.
Electronic Communications Consent*
I consent to authorize U.S. Televero Health, P.A. to send me non-marketing related electronic notifications and communications for appointment information or billing notifications in the form of email, text, SMS, MMS messages.
Parent or Guardian Consent to Treat a Minor*
I consent to authorize U.S. Televero Health, P.A. to provide mental health treatment and care services via telehealth for the minor patient under the age 18 years old as listed herein. I hereby attest that I am the legal parent or guardian of this minor patient.
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ADHD and Stimulant Medication Prescribing Policy*
I attest that I have reviewed and consent to the U.S. Televero Health, P.A. ADHD and Stimulant Medication Prescribing Policy located online at the following link: ADHD and Stimulant Medication Prescribing Policy
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Benzodiazepine and Sleeping Medication Prescribing Policy*
I have reviewed and consent to the U.S. Televero Health, P.A. Benzodiazepine and Sleeping Medication Prescribing Policy located online at the following link: Benzodiazepine and Sleeping Medication Prescribing Policy
Additional Consents*
I attest that I have read in full, understand and consent to the following additional attached terms and conditions herein and located on our website at the following links below and also for download at:
https://televerohealth.com/go/tc522
Telemedicine Informed Consent Form
Website Terms and Conditions of Use
Credit/Debit Card Charge Consent
Appointment Agreement and Promise to Pay
Notice of Privacy Practices
Website Privacy Policy
Parent or Guardian Consent to Treat a Minor
ADHD and Stimulant Medication Prescribing Policy
Benzodiazepine and Sleeping Medication Prescribing Policy
Revocation to Consents*
I understand, agree to, and consent that I have a right to revoke any and all consents and/or authorizations herein ("Consent Revication"), in writing, at any time by sending written notification to the authorized entity U.S. Televero Health, P.A. 6101 West Courtyard Drive, Ste. 2-225 Austin, TX 78730 ("Authorized Entity"). I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.
Patient Consent: My signature below represents that I acknowledge and consent to the terms and conditions herein. I understand that I will receive a copy of this form and all associated terms and conditions upon completion.
Patient/Parent/Guardian Signature*
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date Month Year
Security Code Cardholder Name
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Encrypted Card Details
Credit Card Zip Code*
ZIP Code

Authorize CC on File*
I authorize US Televero Health PA to save my credit card on file. I understand that my credit card will not be charged today with this form submission and my credit card information will be saved on file to be used for any future transactions on my account.
I authorize U.S. Televero Health, P.A. to place my credit card on file. I understand that my credit card information will be saved to file for future transactions on my account.
Untitled

Start My Care Form - Five Minutes to Complete

Patient Info Section

Parent/Guardian Info

Patient Parent/Guardian Address

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OCD Questions