Perfect Balance Psychiatric Services and TMS Center

Step 1

patient information
Pharmacy information

Please provide the following information for E-Prescribing to your preferred pharmacy


I authorize release of the results of my treatment upon conclusion to:

(Guardian’s Signature if Patient is under 18)

Current Medications - List all your medications (including Psychiatric, Physical health, over the counter and herbal medications):

Step 2

Past Psychiartric History
Family History of psychiatric illness
History of Abuse
substance use history
Substances Used Age first started Use frequency Years Used Last use Current use Treatment
Cannabis/ Mj/ Weed
HALLUCINOGENS LSD, PCP, Mushrooms Ecstasy, Nitrous Oxide
Development history
Social history

Step 3


I hereby authorizePERFECT BALANCE PSYCHIATRIC SERVICES PLLC to use disclose, obtain, or release my protected health information (medical records) to/from the named individual or organization listed below. Please fully complete the form. Incomplete forms will be null and void.

This protected health information is disclosed for the following purposes:

I consent my PHI disclosed to the following individuals:

  • I understand that specific information to be disclosed may include Drug, Alcohol Abuse or Mental Health Treatment, information regarding communicable diseases including Human Immunodeficiency Virus (HIV), acquired immunodeficiency syndrome (AIDS), and other medical conditions, laboratory results, treatment and any such related information.
  • I understand that the information released pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA privacy regulations.
  • I authorize that a photocopy of this authorization is acceptable as an original.
  • This authorization will remain in effect indefinitely unless revoked in writing. I understand that my treatment is not conditioned upon my providing this authorization. I understand that I have the right to revoke the authorization at any time by providing a written notification to: The Privacy Officer, Perfect Balance Psychiatric Services, and 9300 John Hickman Parkway, Suite 101, Frisco, Texas 75035. Perfect Balance Psychiatric Services shall not be deemed responsible for release of any information pursuant to this authorization prior to revocation.
  • I understand that there will be a charge of release of photocopies of my medical record. Please indicate below if you need the photocopies of your medical record to be sent to the above named individual or organization.

(Guardian’s Signature if Patient is under 18)

Insurance information/ Responsible Party Information

Step 4


As a Patient receiving services at Perfect Balance Psychiatric Services, we respect, protect, implement and enforce your bill of rights which includes the following:

  1. You have the right to a humane environment that provides reasonable protection from harm and appropriate privacy for your health needs.
  2. You have the right to be free form Abuse, Neglect, and Exploitation.
  3. You have the right to be treated with dignity and respect
  4. You have the right to appropriate services in the least restrictive settings available that meets your needs
  5. You have the right to accept or refuse treatment after receiving this explanation.
  6. If you agree to treatment or medications, you have the right to change your mind at any time (unless specifically restricted by the law)
  7. You have the right to a treatment plan designed to meet your needs, and you have the right to take part in developing that plan.
  8. You have the right to meet with the staff to review and update the plan on a regular basis.
  9. You have the right to refuse to take part in research without affecting your regular care.
  10. You have the right to not receive unnecessary or excessive medication.
  11. You have the right to have information about you kept private and to be told about the times when information can be released without your permission.
  12. You have the right to be told in advance of all the estimated charges and any limitations on the length of services that the clinic is aware.
  13. You have the right to receive any explanation of your treatment or your rights if you have questions while you are in treatment
  14. ou have the right to make a complaint and receive a fair response for the clinic within a reasonable amount of time.
  15. . You have the right to complain directly to the Texas Commission on Alcohol and Drug Abuse any reasonable time.
  16. You have the right have your rights explained in simple terms before receiving services
  17. You have the right to request a copy of these rights including the address and phone number of Texas Commission on Alcohol and Drug abuse.
Department of Investigations
Substance Abuse Services
PO BOX 149347
Austin, Texas 78714

I hereby agree that I have received a clear understanding of my rights at Perfect Balance Psychiatric Services and if I desire, I can be given a copy of these rights for myself.

(Guardian’s Signature if Patient is under 18)