If you would like us to release any aspect of your personal health information from your medical records to another doctor or therapist, family member or organization, please complete our HIPAA authorization form, sign it and send it to me by fax or email. This is also the form that we use if you you would like me to obtain your medical records from another doctor, therapist, lab, or hospital. We make every attempt to respond to your request within 30 days.

HIPAA

HIPAA Authorization

Notice of Privacy Practices

 

Telemedicine

Telepsychiatry is available for established patients within our practice. If you would like to request to be followed, in part, with appointments by phone, FaceTime, or video, please complete our consent form:

Telemedecine Consent Form

 

Mood Chart

It’s often helpful to keep track of symptoms and response to treatment in an organized, visual way by using a daily mood chart. The one we use was originally designed by my colleague, Gary Sachs MD of Massachusetts General Hospital, and adapted for our practice:

Daily Mood Chart

 

Quick Inventory of Depressive Symptomatology (QIDS SR-16)

This scale is a self-report measure of depression.

QIDS SR-16

 

Mood Disorder Questionnaire (MDQ)

The Mood Disorder Questionnaire (MDQ) was developed by a team of psychiatrists, researchers and consumer advocates to address the need for timely and accurate evaluation of bipolar disorder.

Mood Disorder Questionnaire

 

Altman Self-Rating Mania Scale (ASRM)

The ASRM is a 5-item self-rating mania scale, designed to assess the presence and/or severity of manic symptoms. It may be used in an outpatient setting to screen for the presence of and/or severity of manic symptoms for clinical or research purposes.

Altman Mania Scale

 

Zung Self-Rating Anxiety Scale (SAS)

A rating instrument for anxiety disorders. For each item, place a check in the column which best describes how often you felt or behaved this way during the past several days. Bring the completed form with you for scoring and assessment during your office visit.

Zung Anxiety Scale

 

Symptoms of PTSD (PCL-5)

The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including:

  • Monitoring symptom change during and after treatment
  • Screening individuals for PTSD
  • Making a provisional PTSD diagnosis

The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5). When necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis.

Symptoms of PTSD

 

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

A series of question that allow us to understand how severe your Obsessive Compulsive Disorder (OCD) may be.

Yale-Brown OCD Scale

 

Drug Abuse Screening Test (DAST-10)

The following questions concern information about your possible involvement with drugs not including alcoholic beverages during the past 12 months.

Drug Abuse Screening Test

 

Short Form McGill Pain Questionnaire 2 (SF-MPQ-2)

For this questionnaire, I will provide you a list of words that describe some of the different qualities of pain and related symptoms. Please rate the intensity of each of the pain and related symptoms you felt during the past week on 0 to 10 scale, with 0 being no pain and 10 being the worst pain you can imagine. Use 0 if the word does not describe your pain or related symptoms.

McGill Pain Questionnaire

 

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