Patient-Intake Form


Welcome, we are delighted to meet you!

1. Thank you for considering care with Dr. Nathan. This brief screening helps ensure her practice is the right fit for your needs before moving forward. Dr. Nathan values your time and wants to make this process as clear and supportive as possible. Her approach blends traditional psychiatry with mindfulness, compassion, and deep therapeutic connection. To help you decide whether her services align with what you’re seeking, the following information outlines how her practice operates. Please review each item and confirm your understanding so we can determine next steps together. You will be asked to read and confirm your understanding and agreement to each of the following:

This form and any subsequent introductory calls or screenings is solely to determine whether Dr. Nathan’s services are a good fit and does not establish a doctor–patient relationship or include medical advice.


Dr. Nathan does not prescribe controlled substances, including stimulants, benzodiazepines, or other Schedule II–IV medications.

Dr. Nathan does not provide evaluations or documentation for disability claims, work-leave requests, or time-off certifications.

If meeting via telehealth, appointments must take place in a private, confidential, and stationary location within the state of Virginia. Sessions cannot be conducted while a patient is driving or in a moving vehicle or during times in which the patient is not physically located in the state of Virginia.

To move forward with being considered for care, I consent to Dr. Nathan downloading my medication history and conducting a universal review of Virginia's Prescription Monitoring Program (PMP) for compliance.

About You

2. Tell us about YOU!

First Name:

Last Name:

Date of Birth * ​​​​​​​

Gender *

​​​​​​​Address *

Mobile Phone:

Email * ​​​​​​

How did you hear about Dr. Nathan and Heart Centered Psychiatry?

Preferred Method for Appointments [please check all that apply]

3. Do you currently have—or will you become eligible for within the next 90 days—any form of Medicare coverage (including Traditional/Original Medicare, Railroad Medicare, TRS-Care Medicare Advantage, Medicare Advantage plans, or any other Medicare-related program)?

4. Your Reasons for Seeking Care
What brings you to seek treatment at this time?

Medical And Health History

5. Have you received mental health service(s) in the past from a Psychiatrist, Therapist, or other Mental Health Professional?

6. If yes, please expand on this information, briefly including the following information: * What led you to seek care at that time? * When did you receive services (approximate dates)? * What is prompting you to consider a change now?

7. Have you been diagnosed with a mental health or psychiatric condition?

If so, what?

8. Have you ever been hospitalized for mental health reasons?​​​​​​​

If so, when was the most recent time? Can you briefly describe the circumstances?

9. Have you ever attempted suicide or engaged in self-harm?

If so, when was the most recent time? Can you briefly describe the circumstances?

10. Have you ever been diagnosed with or received treatment for an eating disorder (such as anorexia nervosa, bulimia nervosa, binge eating disorder, or another eating-related condition)?


If yes, briefly provide details:

11. Do you use recreational drugs?

If yes, briefly provide details:

12. List all medications you are taking, including any over-the-counter medications, herbs or vitamins:

13. Do you have any known allergies?

14. If yes, please list any allergies:

15. Have you ever been detained, arrested, or experienced adverse consequences for physical aggression in the past?​​​​​​​

If so, when was the most recent time? Can you briefly describe the circumstances?

16. Do you currently have any open or ongoing legal cases (civil or criminal) that you believe may impact your mental health or ability to participate in treatment?​​​​​​​

If so, please briefly describe the nature of the case and whether it is ongoing or pending resolution.

About Working Together

17. Please describe your main concerns in a few sentences.

18. Is there anything else you'd like Dr. Nathan to know before scheduling a consultation?

Coverage for Sessions

19. How are you hoping to cover your sessions?​​​​​​​

20. Primary Insurance

Primary Insurance Company​​​​​​​

Member ID / Policy #

Group Number

Client Relationship to Insured​​​​​​​

Insured Name

Insured Phone:

Insured Date of Birth * ​​​​​​​

Insured Sex

Insured ​​​​​​​Address *

Do you have a secondary insurance you would like to use?

21. Secondary Insurance

Secondary Insurance Company​​​​​​​

Member ID / Policy #

Group Number

Client Relationship to Insured​​​​​​​

Insured Name

Insured Phone:

Insured Date of Birth * ​​​​​​​

Insured Sex

Insured ​​​​​​​Address *

22. Primary Insurance Card - please upload a copy of the front and back of the card

23. Secondary Insurance Card - please upload a copy of the front and back of the card

What to Expect Next

  • All submitted forms are reviewed by our team to determine whether Dr. Nathan’s practice is an appropriate fit for your needs. Submission of this form does not guarantee acceptance into care.
  • A member of our team will contact you within 48 business hours to discuss next steps, including availability, fees, and scheduling. Please note that business hours do not include weekends or holidays.

Important Safety & Care Information

Dr. Nathan’s practice is not an emergency service and does not provide crisis intervention.

  • If you are experiencing a medical or psychiatric emergency, please call 911 or go to the nearest emergency room.
  • If you are experiencing thoughts of self-harm or suicide, you may call or text 988, the Suicide & Crisis Lifeline, available 24/7.


​​​​​​​Completion of this screening form, and any related phone calls or communications, does not establish a physician–patient relationship and does not constitute medical advice, diagnosis, or treatment.

Thank you for taking the time to complete this screening. We appreciate your thoughtfulness in helping us ensure the best possible match for care.

By submitting this form, you confirm that the information you have provided above is true, complete, and accurate to the best of your knowledge. [Please sign and be sure to click the "Submit Form" button]

Signature(Initial)

Date

Medicare Private Contract

I Geeta Nathan, M.D. (provider’s name) have been excluded from Medicare under sections 1128, 1156 or 1892 of the Social Security Act.

I (the Medicare beneficiary) or my legal representative accept full responsibility for payment of charges for all services furnished by Geeta Nathan, M.D. (provider’s name).

I (the Medicare beneficiary) or my legal representative understand that Medicare limits do not apply to what Geeta Nathan, M.D. (provider’s name) may charge for items or services furnished.

I (the Medicare beneficiary) or my legal representative agree not to submit a claim to Medicare or to ask Geeta Nathan, M.D. (provider’s name) to submit a claim to Medicare.

I (the Medicare beneficiary) or my legal representative understand that Medicare payment will not be made for any items or services furnished by Geeta Nathan, M.D. (provider’s name) that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.

I (the Medicare beneficiary) or my legal representative enter into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted-out of Medicare, and I am not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.

The expected or known effective date and expected or known expiration date of the opt-out period is _______________________________ (today's date) and two years from today's date (expiration date).

I (the Medicare beneficiary) or my legal representative understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.

This contract cannot be entered into by me, (the Medicare beneficiary), or by my legal representative during a time when I, (the Medicare beneficiary), require emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 3044.28 of the Medicare Carriers Manual).

I (the Medicare beneficiary) or my legal representative will receive or have received a copy (a photocopy is permissible) of this contract, before items or services are furnished to me under the terms of this contract (you will be provided a copy of this document at your initial appointment).

I Geeta Nathan, M.D. (provider’s name) will retain the original contract (original signatures of both parties required) for the duration of the opt-out period.

I Geeta Nathan, M.D. (provider’s name) will supply CMS with a copy of this contract upon request.

I Geeta Nathan. (provider’s name) understand that the current private contract remains in effect for two years. If I again opt-out of Medicare, I will expediently complete a new contract for each Medicare beneficiary and will expediently submit the appropriate affidavit(s) to all local Medicare carriers.

Provider’s NPI: XXXXXXXXX

Client Signature (Initial)

Date

Provider Signature (Initial)

Date