Templates Included in PracticeQ Set-Up

Questionnaires **

• Online Intake Form

• Request for an Appointment
• AUDIT Screening Tool
• Adult ADHD Self Report (ASRS v1.1) Symptom Checklist
• Adult ADHD-RS-IV with Adult Prompts
• Beck Anxiety Inventory (BAI)
• Beck Depression Inventory (BDI)
• CAGE Screening Tool
• Clinical Opioid Withdrawal Scale (COWS)
• Columbia Suicide Severity Rating Scale (for Provider to Ask)
• COVID-19 Health Screen Form
• Drug Abuse Screening Test (DAST-10)
• Eating Attitude Test (EAT-26)
• Eating Disorder Diagnostic Scale (EDDS)
• Edinburg Postnatal Depression Scale (EPDS)
• Generalized Anxiety Disorder (GAD-7)
• Generalized Anxiety Disorder (GAD-7 Child)
• Goldberg Mania Scale
• Good Faith Estimate – Psychiatric Practices
• MDQ
• Montgomery and Asberg (MADRS) Depression Rating Scale
• NICHQ Vanderbilt Assessment Scale – Parent Informant
• NICHQ Vanderbilt Assessment Scale – Teacher Informant D4
• NICHQ Vanderbilt Assessment Scale – Parent Informant D5
• NICHQ Vanderbilt Assessment Scale – Teacher Informant D6
• Panic Disorder Severity Scale
• Pediatric Psychiatric Medication History
• Psychiatric Medication History
• PHQ-9
• PHQ-9 Child
• PHQ-9 Modified for Teens
• PHQ-9 Parent Report
• Prediction of Alcohol Withdrawal (PAWSS)
• Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5)
• Rapid Mood Screener (RMS)
• Social Phobia Scale
• Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
• Young Mania Rating Scale (YMRS) (Parent)

Consents

• Welcome Letter
• Spruce Communication Flyer (if you are using Spruce)
 • Good Faith Estimate – Nurse Practitioner
• Mental Health and Wellness Treatment Agreement
• Telehealth Consent, Policy and Agreement
• HIPAA Privacy Policy
• No Show / Cancelation / < 24 Hr Reschedule Policy
• Credit Card on File Consent
• Medication History Consent
• Disability Forms Policy
• Controlled Substance Policy
• Consent to Release Medical Records (TO)
• Consent to Release Medical Records (FROM)
• Consent to Bill Medicare (if needed)
• Consent for Stimulant Use
• Patient Election for Self-Pay Services
• Revocation of Patient Election to Self-Pay for Services

Note Templates

• Initial Psychiatric Evaluation

• Follow-Up Psychiatric Evaluation
• Abnormal Involuntary Movement Scale (AIMS)
• Collection / Payment Contact
• Discharge /Termination Letter
• Emotional Support Animal Letter (ESA)
• Hamilton Anxiety Rating Scale (HAM-A)
• Hamilton Depression Rating Scale (HDRS)
• Insurance Verification
• Lab / Testing Order
• Late Cancellation / No-Show
• Blank Letterhead
• Medication Order Form
• Medical Records Request
• Progress Note
• Nurse / Assistant Call
• Patient Safety Plan
• Provider Call / Contact
• School Medication Note
• Return to Work / School
• Y-BOCS Symptom Checklist
• Young Mania Rating Scale (YMRS)
• Gastric Bypass Clearance

** All licenses for any screening tools are the responsibility of the provider utilizing the
tools. You are paying Silver Leaf PMS for the creation of these tools – NOT including the
licenses if applicable.