Gary Dunham, PA-C Nicholas Gaultney, PMHNP- BC Jennifer Harris, PA-C Suzanne Perakathu, PMHNP-BC Rozalia Carrasco, PA-C

PATIENT INFORMATION:

<;;enesis <Beliaviora[ Jfea{tfi Edmund P. "Ted" Williams, IV, M.D.

7122 Stonewall Hill San Antonio, Texas 78256

Office (210) 404-9696 Fax (210) 404-9466

Last Name: ________ First Name: ________ MI: Suffix:

Denise Castro, LPC Kristin Collins, LPC Hunter Verheul, LPC Carly Ward, LPC

□Male □Female

Date of Birth: ______ Age: ___ Marital Status: ______ Occupation: _____ _

Social Security#: ___________ Driver License# /State: _____ _______ _

Home Address: _______________________ Apt#: _______ _

City: ________________ State: ______ Zip Code: ________ _

Home Phone: Cell Phone: Work Phone: Other:

E-mail:

----- ------ ------ ------

------------------------------------

What is the best way to reach you: D-Home□ -Cell □ -Work □-Other May we contact you at work? Y N

Emergency Contact: __________ Relation: ______ Phone: _________ _

Preferred Pharmacy Name: Phone: ____ _

Primary Care Physician: _________________ Phone: _________ _

Address: ------------------------------------

Ref erred by: Phone:

PARENT /GUARDIAN/RESPONSIBLE PARTY □SELF D OTHER (Please complete if other)

Last Name: ________ First Name: ________ MI: Suffix: □Male □Female

Home Address: _______________________ Apt #: _______ _

City: State: Zip Code: ________ _

Home Phone: Cell Phone: Work Phone: Other: ----- ------ ------ ------

Social Security#: ________ Driver License# /State: ________ DOB: _____ _

Employer: Position/Title:

INSURANCE INFORMATION - Please present Insurance cards at EVERY visit.

PRIMARY Insurance Company: _______________ Policy#: ________ _

Group#: ________ Effective Date: _________ Employer: ________ _

Policy Holder Name: Policy Holder DOB: ___________ _

Policy Holder Social Security#: Relationship to patient: _______ _

SECONDARY Insurance Company: Policy#: ________ _

Group#: ________ Effective Date: _________ Employer: ________ _

Policy Holder Name: Policy Holder DOB: ___________ _

Policy Holder Social Security#: Relationship to patient: _______ _

10. abuse of staff and lack of a good fit. The patient ( or the patient's legal representative) has the right to terminate treatmentat his/her discretion. Upon either party's decision to terminate the relationship, the provider will continue care for atleast 30 days and recommend more appropriate resources.

11. LEGAL AND COURT-RELATED MATTERS: Dr. Williams and the providers with Genesis Behavioral Health do notparticipate in court-related matters, such as divorce or child support cases. However, if court-related work is required,the practices' cost related to that work is the sole responsibility of the patient and/ or their responsible party. Thesematters include but are not limited to: preparation, communication with involved parties, depositions, testimony, standbyefforts, attorney fees, and other costs incurred as a direct result of the matter.

12. EDUCATION: Genesis Behavioral Health is a teaching site for the University of Texas Health Science Center at SA(UTHSCSA). You may be asked to allow students to join your session. The choice is entirely yours. We appreciate yourcontribution to their medical education.

13. PROMOTIONAL ACTIVITIES FOR PHARMACEUTICAL COMPANIES: Dr. Williams has contracts with severalpharmaceutical companies to educate other physicians about their products. These are promotional programs he istrained and paid to give.

14. COLLECTION AGENCY: In the event of a delinquent account balance, I will be responsible for all collection fees assessedby the collection agency onto the account.

15. CONSENT TO TREATMENT: I consent to evaluation and treatment of myself, my minor child or ward.

16. ASSIGNMENT OF BENEFITS: I hereby authorize my insurance benefits to be paid directly to Genesis Behavioral Healthand understand that I am financially responsible for non-covered services. I also authorize Genesis Behavioral Health torelease any information to my insurance company required to process claims.

Patient Name (please print) Patient or Authorized Representative Signature Date

*Digital Signature

Gary Dunham, PA-C

Nicholas Gaultney, PMHNP- BC

Jennifer Harris, PA-C

Suzanne Perakathu, PMHNP-BC

Rozalia Carrasco, PA-C

qenesis <Behavior a{ Jfea{th Edmund P. "Ted" Williams, IV, M.D.

7122 Stonewall Hill

San Antonio, Texas 78256

Office (210) 404-9696 Fax (210) 404-9466

Denise Castro, LPC

Kristin Collins, LPC

Hunter Verheul, LPC Carly Ward, LPC

Authorization Form for Release of Protected Health Information with Family or Friends

Patient Name: __________________ Date of Birth: ___________ _

I grant permission for my healthcare provider and their representatives of Genesis Behavioral Health to

discuss my care using this disclosure form to share relevant information about my healthcare or discuss financial information for payment on my account.

Release my protected health information to the following person(s)/entity:

Name: ____________ Phone: ___________ Relationship: ______ _

Name: ____________ Phone: ___________ Relationship: ______ _

The information you may release subject to this authorization is the following:

Appointment date/time □Yes □No

Lab Reports □Yes □No

Explanation of diagnosis and/treatment plan □Yes □No

Billing Information □Yes □No

□ I do not want any of my information shared with family or friends

I consent to Genesis Behavioral Health to leave a message on my voicemail regarding my lab care:

□Yes □No

I understand that my healthcare information at Genesis Behavioral Health is protected. By signing this form, you are granting Genesis Behavioral Health to disclose your protected health information for the purpose of treatment, payment and health care operations. Our Notice of Privacy Practices provides

more detailed information about how we may use and disclose this information. The terms of our Notice

may change, and if so, you may obtain a revised copy by contacting our office. If you would like a copy of our Notice of Privacy Practices, please see the front desk.

Patient/ Authorized Representative Signature Date

This consent will be considered valid until such time that I revoke it. I reserve the right to revoke it at any

time. I understand that to revoke this consent, I must provide written notice to Genesis Behavioral Health.

*Digital Signature

INITIAL PSYCHIATRIC EVALUATION 20200225

ADULT

Age 18 and older (after high school)

Genesis Behavioral Health

Name: _____________ _ DOB: -----

Age:__ Date: ___ _

Name of others with you today: □ No one, I came alone today □ Spouse/Other: Name, relationship to you. _________ _

Do you see a therapist for talk therapy? □No □Yes Name: __________________ _

How did you hear about us? If someone referred you, who? ____________________ _ Check all that appl : □ Insurance com an □ Thera isl □Ph sician □Friend □Internet o TV Commercial □Other

BACKGROUND INFORMATION

Tell us about your family & living situation

Names of those living in the same household and names of children &

step-children not living with you:

□ No one lives with me. I live alone.

Living with you?

□Yes □No

□Yes □No

□Yes □No

□Yes □No

□Yes □No

□Yes □No

Name

MARITAL ISSUES/ SIGNIFICANT OTHERS

Are you married? □ Yes □ No

If NO, are you in a steady relationship? □ Yes □ No

How would you rate your relationship?

Relationship to you

□ Happy □ Fairly happy □ Just OK □ Fairly unhappy □ Very unhappy

If VERY UNHAPPY, please write briefly in the space provided below what thegeneral nature of the problems are.

Have you ever been divorced? □Yes □No If yes, how many times? __

Have you ever been remarried? □Yes □No If yes, how many times? _ _

Educational, Work, Legal & Religious History

Occupation: ________________ _ How would you rate your work satisfaction? □ Very happy o Fairly happy

□ Just OK □ Fairly unhappy D Very unhappy

If VERY UNHAPPY, please write briefly below what the general nature of the

problems are.

Education: Current or highest grade level? _______ _

If in school, how are grades? ____ ________ _

History of learning difficulty? _______ _____ _

Legal - Have you had any legal problems or ongoing problems with custody

issues? o No □ Yes

Describe: ____________ ______ _

Spiritual History

Are you a Christian? □ No □ Yes □ Unsure

Other Religious beliefs? _____________ _

How important to you is faith in God:

□ Important □ Somewhat Important □ Not Important

Do you now or have you ever met with others in religious or spiritual

community? □No □Yes

How important is or was this to you?

□ Important □ Somewhat Important □ Not Important

THE PROBLEM WHICH BRINGS YOU HERE: You ma write on the other side if needed

Why are you here? (Briefly explain the problem that brings you here now and what stressful circumstances have contributed to it.) (750 characters)

Page 1 of 4

Patient Initials ___ __ _

SUICIDAL THOUGHTS, ATTEMPTS, OR SELF-HARM

CURRENT THOUGHTS OF SUICIDE OR DEATH SELF MUTILATION □ I do not think of suicide or death - if checked, skip this section

□ I have not ever hurt myself physically to distract myself□ No □ Yes - I feel that life is empty or wonder if it's worth living from emotional pain - if checked, may skip to next section□ No □ Yes - I have wished I were dead or wished I could go to sleep and □ I used to feel like cutting or hurting myself to deal with

not wake up. emotional pain, b t not any more□ No□ Yes - I Have been having thoughts of killing myself □ Recently I have felt like cutting or hurting myself□ No□ Yes - I have been thinking about how I might do this. □ I think about cutting or hurting myself several times a day□ No □ Yes - I am thinking about actina on these thoughts Comments: (190 characters)

□ No □ Yes - I have started to work out or have worked out the details ofhow to kill myself.

OTHER SYMPTOMS

SOCIAL ANXIETY SYMPTOMS POST-TRAUMATIC STRESS SYMPTOMS

□ A persistent fear of being embarrassed or looking foolish, □ You have experienced a very significant traumatic event.

especially around unfamiliar people, i.e. very shy If YES, what? □ You avoid situations in which you might be embarrassed so much □ Distressing memories or nightmares

that it interferes significantly with your ability to function normally □ Easily startled, always 'on guard'□ Feeling numb, unreal, or detached

OBSESSIVE-COMPULSIVE SYMPTOMS □ You avoid situations reminding you of the trauma

□ Do you wash or clean a lot? EATING ISSUES

□ Do you check things a lot? □ Constantly dieting despite others saying you're thin□ Is there any thought that keeps bothering you that you would like to □ Binge eating or purging

get rid of but can't?□ Do your daily activities take a long time to finish? ANGER & AGGRESSION

□ Are you concerned about putting things in a special order or Do you have (too frequently) sudden outbursts of anger? □Yessymmetry, or is very upset by mess?□ Compulsive hair pulling (Trichotillomania) With aggression? □Yes□ Compulsive pornography Are you having thoughts of hurting someone else?

□Yes□ Compulsive internet use OTHER SYMPTOMS

□ Compulsive shoppina□ Compulsive stealing Are there times that you feel fine one minute and then become tearful □ Are you very concerned and preoccupied about the appearance of (or laughing) the next minute over something small or for no reason at all. some part(s) of your body which you consider especially unattractive?

Do you detect hidden meanings in what people say or do? PHOBIAS/SPECIFIC FEARS Do you often feel persecuted?

o Fear of going out or going certain places Feel that people can read or control your thoughts? □Yes

□ Other specific fears? If so, what? Hallucinations (hear voices or see thinqs)

DEVELOPMENTAL, ABUSE, & TRAUMA HISTORY

□Yes□Yes□Yes

□Yes

Was your childhood: □ Basically happy □ Painful Why? _ _ _ _ _ ____ __ _ _______________ _ Were you a victim of past: □ Physical abuse? □ Neglect? □ Emotional abuse? □ Sexual abuse? □Other?

Explain briefly:(390 char.)

EXERCISE

In a typical week, how many times do you exercise at least 20-30 min (any type, or brisk walking or yoga)?

□ None □ 1 time □ 2 times □ 3 times □ 4 times □ 5 times □ 6 times

Page 2 of 4

□ 7 times

PATIENT INITIALS ___ _ _ _ RELATIONSHIPS AND SOCIAL SUPPORTS

SOCIAL SUPPORTS

o Yes o No Do you experience a lot of loneliness?o Yes o No Do you have a close confidant other than spouse? How often do you talk? _ __ _____ ______ __ _

OTHER CONFLICTUAL RELATIONSHIPS

o Yes o No Are you having significant conflict or stress with anyone other than your spouse? If so, who? __________ _About what?

SLEEP ISSUES

IN THE LAST TWO WEEKS:

Do you qenerally feel rested when you wake up in the morninq? □ Yes □ No What time do you typically go to bed? What time do you typically fall asleep? What time do you typically wake up? Including naps during the day, how many hours, on averaqe, do you sleep per 24-hour day? If you awaken frequently through the night, how many times do you awaken, and how long does it take you to go back to sleep?

If so, you awaken approximately times? Time it takes to qet back to sleep: Do you struggle to stay awake when you should be awake? □Yes Is your work, home, or social life negatively affected by excessive sleepiness, or, for example drivinq a car? □Yes Do you have a tendency to snore? □YesHave you been told that you stop breathing briefly at times while you are sleepinq at niqht? □Yes Have you been prescribed CPAP? □Yes If Yes, do you use it reqularly? □Yes Do you work shifts or a nontraditional schedule (could include being a caregiver for infant or elderly)? □Yes

THE EPWORTH SLEEPINESS SCALE is used to determine the level of daytime sleepiness. A score of 10 or more is considered sleepy. How likely are you to doze offor fall asleep in the following situations, in contrast to feeling just tired? Use the following scale to choose the most appropriate number for each situation.

SITUATION CHANCE OF DOZING OR FEELING SLEEPY 0 = none

Sitting and reading Watching TV 1 = slight

Sitting inactive in a public place (for example: a theater or a meeting) 2 = moderate

As a passenger in a car for an hour without a break 3 = high

Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone

□ Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic Total Score

PROBLEMS WITH EMOTIONAL INST ABILITY

Having problems with emotional instability means having unstable_relationships, low self-esteem, and problems with impulsive behavior, beginning by early adulthood. A common feature of this emotional instability is fear of being left alone (abandoned), even if the threat of being abandoned is not real. This fear may lead to frantic attempts to hold on to others and may cause them to become overly dependent on how others feel about them. Angry mood swings and erratic behavior can lead to troubled relationships in many areas of life.

Problems with emotional instability - do you tend to: □ Make frantic efforts to avoid real or imagined abandonment.

□ Have a pattern of difficult relationships caused by alternating between extremes of intense admiration and hatred of others.□ Have an unstable self-image or be unsure of his or her own identity.□ Act impulsively in ways that are self-damaging, such as extravagant spending, sex with many partners, substance abuse, binge eating,

or reckless driving.

□ Have recurring suicidal thoughts, make repeated suicide attempts, or cause self-injury through mutilation, such as cutting or burning oneself.□ Have frequent emotional overreactions or intense mood swings, including feeling depressed, irritable, or anxious.

These mood swings may only last a few hours at a time. In rare cases, they may last a day or two. □ Have long-term feelings of emptiness.

□ Have inappropriate, fierce anger or problems controlling anger - or often display temper tantrums or get into fights.

□ Have temporary episodes of feeling suspicious of others without reason (paranoia) or losing a sense of reality.

Page 3 of 4

CURRENT and PAST MEDICATIONS

List ALL CURRENT MEDICATIONS, VITAMINS, HERBAL, & SUPPLEMENTS that you are now taking: Medication, Vitamin, or Herbal Medication, Vitamin, or Herbal

List ALL PAST MEDICATIONS that vou have taken·

✓ ifTaking Medication When & Why Sto1:11:1ed When ✓ ifTakin<l Medication Now or Past Have you ever taken any of Now or Past Have you ever taken any of

these dose these: □Now □Past Ritalin/Methylin ::iNow □Past Ability (Aripiprazole) □Now □Past Metadate oNow □Past Aristada or Maintenna

1,Now □Past Quillivant/Quillichew □Now ciPast Rexulti

uNow □Past Aptensio □Now ciPast Geodon (Ziprazidone)

DNow DPast Concerta (Methylphenidate) □Now ciPast Risperdal (Risperidone)

1JNow □Past Focalin (or XR) □Now □Past lnvega (Paliperidone) {dexmethylphenidate)

DN0W □Past Daytrana ::iNow □Past Zyprexa (Olanzapine)

□Now DPast Adderall (or XR) ::iNowoPast Quetiapine (Seroquel) (dextroamphetamine)

uNowoPast Vyvanse ::iNow ,::iPast Saphris

□Now □Past Mydayis ::iNow □Past Fanapt

CJNOW □Past Dyanavel ::iNow 1-.iPast Latuda

□Now uPast Other stimulant ::iNow DPast Vraylar

1::iNow DPast Strattera (Atomoxetine) DNow c,Past Clozapine

DNow □Past Kapvay (Clonidine) ::iNowDPast Lithium

DNowoPast lntuniv (Guanfacine) □Now DPast Depakote (Valproic Acid)

DNow □Past Prozac (Fluoxetine) ::iNow □Past Tegretol (Carbamazepine)

oNow DPast Zoloft (Sertraline) DNow DPast Trileptal (Oxcarbazepine) □Now □Past Paxil (Paroxetine) □Now ciPast Lamictal (Lamotrigine) □Now □Past Luvox (Fluvoxamine) □Now□Past Topiramate (Topamax)

□Now □Past Celexa (Citalopram) □Now□Past Valium (Diazepam)

□Now □Past Lexapro (Escitalopram) □Now □Past Xanax (Alprazolam)

□Now uPast Effexor XR (Venlafaxine) □Now □Past Ativan (Lorazepam)

□Now □Past Pristiq (Desvenlafaxine) □Now □Past Klonopin (Clonazepam

□Now□Past Cymbalta (Duloxetine) □Now□Past Lyrica (Pregabalin) □Now □Past Wellbutrin (Bupropion) oNowoPast Neurontin (Gabapentin)

□Now □Past Remeron (Mirtazapine) □Now□Past Vistaril (Hydroxyzine)

□Now □Past Buspar (Buspirone) □Now □Past Ambien (Zolpidem)

□Now □Past Trintellix □Now DPast Lunesta (Eszopiclone) □Now □Past Viibryd :iNow□Past Temazepam

oNowoPast Fetzima :iNowoPast Sonata

□Now□Past Nefazodone :iNowDPast Belsomra

□Now □Past Amitriptyline :iNowoPast Trazodone

□Now □Past lmipramine :iNow DPast Rozerem

□Now □Past EMSAM pNow DPast Melatonin

□Now □Past Nardil pNow □Past Benadryl (antihistamine) □Now□Past Parnate pNow □Past Other OTC sleep aid □Now □Past Ketamine □Now□Past Aricept ( donepezil) □Now □Past Provigil (Modafanil) □Now□Past Namenda (memantine) □Now □Past Nuvigil (Armodalanil) pNow □Past Buprenorphine □Now □Past Prazosin pNow □Past Antabuse (disulfiram) □Now □Past Naltrexone (oral or injectable) pNow □Past Campral (acamprosate)

Page4 o/4

Medication, Vitamin, or Herbal

When & Why Sto1:11:1ed

dose

When

20180605 TMS

Genesis Behavioral Health

TMS CONSULTATION Transcranial magnetic stimulation

Name: ___________________________________ DOB: __________ Age: ______ Date: __________ Name of others with you today: Spouse/Other: Name, relationship to you: _________________________________ When was the first time you were depressed? (best estimate) When was the first time you were treated for depression? (best estimate) When did this episode of depression begin? (best estimate) What symptoms of depression are the MOST DIFFICULT for you? ☐ Low energy/motivation ☐ Down mood ☐ Difficulty enjoying pleasurable activities ☐ Difficulty sleeping☐ Frequent negative thoughts (about yourself, the world, and the future) ☐ Thoughts of not wanting to go on living

In what areas is depression affecting your ability to function normally? ☐ Work/school performance ☐ Social Interaction ☐ Family/Home responsibilities ☐ Hobbies/Interests☐ Activities of daily living (examples: difficulty getting out of bed, grooming yourself as you normally do)

What SIDE EFFECTS have you experienced from your medications? ☐ Sedation/Tiredness ☐ Anxiety ☐ Suicidal Thoughts ☐ Sexual Dysfunction ☐ Insomnia ☐ Blurred vision☐ Constipation ☐ Headache ☐ Weight Gain ☐ Tremor ☐ GI upset/Nausea ☐ Dry mouth☐ Irritability/Anger ☐ Sweating ☐ Withdrawal symptoms

What OTHER FACTORS have contributed to your depression? ☐ Anxiety ☐ Chronic pain ☐ Medical problems ☐ Financial stressors☐ Relationship problems ☐ Painful childhood ☐ Traumatic experiences ☐ Unresolved grief

PSYCHOTHERAPY ☐ Yes ☐ No Have you had psychotherapy for depression? What kind: ☐ CBT ☐ Other ________________________ ☐ Unsure

Approximately how many sessions? __________________ When? ____________________________________

ADDITIONAL CONSIDERATIONS FOR TMS ☐ Yes ☐ No ☐ Unsure Have you ever received TMS with a successful outcome? If so, when: ___________________________

☐ Yes ☐ No ☐ Unsure Have you received ECT (electroconvulsive therapy)?

☐ Yes ☐ No ☐ Unsure Do you have a history of seizure disorder?

☐ Yes ☐ No ☐ Unsure Have you had chronic psychotic symptoms, such as hallucinations present in schizophrenia?

☐ Yes ☐ No ☐ Unsure Do you have an implanted magnetic-sensitive medical device inside your head or other implanted

metal items, including but not limited to a cochlear implant, implanted cardioverter defibrillator (ICD), pacemaker, vagus nerve stimulator (VNS), or metal aneurysm clips or coils, staples, or stents. (Note: Dental amalgam fillings are not affected by the magnetic field and are acceptable for use with TMS).

Insurance: ☐ BCBS ☐ Cigna ☐ Humana ☐ Aetna ☐ Other ___________________

PAST AND CURRENT MEDICATIONS

On the previous page is a list of medications. IF YOU FILLED IT OUT IN THE PAST, PLEASE FILL IT OUT AGAIN. We understand that you may not remember the details, but just do the best you can. It is very important for us to know your past and current medications.