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Patient Forms

All of our patient forms are online. Once completed, they can be directly submitted to us with a simple click.

Click on the appropriate folder to find the form that you need.

Complete the form as directed and when finished, click submit. All information is sent directly back to our office.

Signature Page - Consent for Telepsychiatry Form [click here]

1. Signature Page – Consent for Telepsychiatry Form

 

Treatment of Child/Minor (under 18 years of age) [click here]

1. Child/Minor Consent for Treatment

2. Signature Page-Consent for Telepsychiatry Form

Substance Use – Medication Assisted Treatment (MAT) [click here]

1. Signature Page-Consent for Telepsychiatry Form

2. Substance Use Treatment Agreement (MAT)

Office Policies, Release of Information & Consent For Treatment [click here]

1. Emerald Psychiatry’s Office Policies (PDF)

2. Our Privacy Practices (PDF)

3. Release of Medical Information

4. Informed Consent (PDF)

Emerald’s Response to “Responsible Restart Ohio” Protocols

Please note that as of April 28th, ALL PSYCHIATRIC MEDICATION MANAGEMENT APPOINTMENTS AND THERAPY/COUNSELING APPOINTMENTS WILL CONTINUE TO BE DONE VIA TELEPSYCHIATRY WITH THE EXCEPTION OF TMS TREATMENTS, WHICH WILL CONTINUE TO BE DONE IN OUR OFFICE. Although some types of medical encounters/procedures will be “restarting” in the coming weeks, it has been made clear that any work that can be done remotely, should continue to be done remotely. Our patients have reported overwhelmingly positive responses to our telepsychiatry services. We will continue to practice recommended social/physical distancing at this time through telepsychiatry appointments, other than TMS treatments. Emerald will continue to monitor any changes in recommendations from the state of Ohio and will update this section as necessary.