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New Patient Form:

Patient Consent & Responsibility:

The agreement is between Dayna Giordano APRN and all practitioners including therapists in the group of Dayna Giordano APRN and CT Pain, Addiction and Psychiatric Services INC. The client is providing consent and collaboration within the group to treat all medical, psychiatric or addiction conditions that are mutually agreed upon between the patient, provider or clinicians that may present. By giving consent, the patient understands that the following are grounds for discharge from the providers care, (list may not be all inclusive), no-call no-show three times with less than 24 hours' notice, repeated rescheduling by patient as determined by the provider, failure to adhere to prescribed medications, not follow prescribed regime, missed therapy appointments (must attend twice per month or more if required), inappropriate behavior, seeing more than one provider for the same medications, failure to pay co-pays or insurance balances at the time of visit or otherwise. 

Dayna Giordano and CT Pain Addiction and Psychiatric services does not bill under Mental Health Insurances. We are a Multispecialty Practice billing under Medical. I hereby authorize direct payment of medical benefits to the provider, for services rendered by the provider or providers under their supervision. I understand that I am financially responsible for any balance not covered by my insurance company. Collection of any account balances past due 3 months after billing date may be assigned to a collection agency. I authorize Dayna Giordano APRN and CT Pain, Addiction and Psychiatric Services, to release any medical information necessary to process my claims and determine if benefits are payable or not. I authorize the third-party billing company to process my claim and will act as a secondary process for claims & payments due on behalf of the agency. 

The provider may contact emergency services or emergency contact of a patient at any time the provider deems necessary, for example, if a provider feels the patient is unable to drive safely, unable to contact patient, hospitalize the patient, or if the provider feels it is in the best interest of the patient. The patient agrees to allow providers to work collaboratively to ensure the provision of coordinated professional services for all individuals who seek treatment at the agency to enhance and acknowledge communication, provide education, and preserve the rights of each client. 

Medication Agreement and Refill Policy:

The purpose of the agreement is to protect your access to controlled substances and to protect our ability to prescribe to you. The long-term use of such substances such as opioids (narcotic analgesics), benzodiazepine tranquilizers, amphetamine-salts (stimulants and sedative hypnotics are controversial because of the uncertainty regarding the extent of which they provide long-term benefit). There is also risk of an addictive disorder or development of tolerance and possible relapse in those persons with prior addiction. The extent of this risk is not certain because these drugs have potential for abuse and diversion (selling prescriptions). Strict accountability is necessary when use is prolonged. For this reason, the following policies are agreed to, by you, the client as a consideration for and a condition of the willingness of the provider whose signature appears below the initial for continued prescription of controlled substances to treat your medical condition.

Disability Assistance Policy:

Dayna Giordano APRN adheres to the following policy regarding assistance with applications for Social Security Disability Insurance (SSI) or other disability-related services:
Voluntary Assistance: 
Any assistance provided by Dayna Giordano APRN in filling out disability-related forms or managing related processes is purely voluntary and at the discretion of Dayna Giordano APRN.
No Legal Obligation: 
Dayna Giordano APRN is not legally obligated to assist any individual in applying for SSI, disability benefits, or any other forms of government aid. Our involvement and support do not guarantee any outcomes related to the approval or denial of such benefits.
Limitation of Responsibility: 
Dayna Giordano APRN shall not be held responsible for the outcome of disability claims, including approvals, denials, or any legal disputes arising thereof.
Right to Refuse Service: 
Dayna Giordano APRN reserves the right to refuse assistance in any situation deemed inappropriate or beyond the scope of our expertise or capacity.
This policy is meant to clarify the extent and limits of the support provided by Dayna Giordano APRN and to prevent misunderstandings and unwarranted blame regarding the disability application process.

General Agreement:

All controlled substances must come from the provider whose signature appears below or from another provider in the practice. The client is expected to inform our office of any new medications, medical conditions, or any adverse effects you may have from any medication you take. The client must inform us of any recent hospitalizations and be seen in the office not longer than two weeks post discharge and bring all discharge paperwork and instructions to the visit no later than 2 weeks post discharge.

Opioid and benzodiazepine medications should not be stopped abruptly, as withdrawal will likely develop. Original containers of medications should be brought to the office and a pill count will be done monthly. Any medical or psychiatric treatment is initially a trial and continued prescriptions are contingent on evidence of benefit. The risks and potential benefits of these therapies ae explained and that you acknowledge that your give consent to start treatment with opioids or Medication Assisted Treatment (MAT).

Initiation of treatment will be started when all appropriate paperwork is completed, appropriate labs are reviewed in the past 90 days (about 3 months) and all radiology reports and physician documentation of non-cancer medical conditions are reviewed. Medication will be prescribed on the second office visit and a plan of care will be initiated. 

The Patient agrees not to retaliate against the Provider in any way, including verbally, physically, emotionally, or through any communication medium. Retaliation includes actions intended to harm, intimidate, or distress the Provider due to dissatisfaction with services. The Patient commits to expressing concerns professionally and respectfully. Violation of this clause may result in termination of the professional relationship, restricted access, and potential legal consequences. This clause aims to safeguard the Provider's well-being and integrity.

Safeguarding Your Medication:

The client may not share, sell, or otherwise permit others to have access to your medications. Because the drugs may be hazardous or even lethal to a person who is not tolerant to their effects, especially a child, you must keep all medications out of reach and a lock box is advised to keep your medications safe. Prescriptions and bottles of these medications me be sought by other individuals with chemical dependency and should be safely safeguarded. Please do not leave your medication in your car or in someone else's home. It is expected that you will take the highest possible degree of care with your prescriptions. Medications will not be prescribed even if it is stolen. If your medications are stolen, please alert the authorities ASAP. Medications lost, stolen, or misplaced will not be reordered. Prior authorization (PA) or any time spent getting your medications will not be done in this office for any reason by our providers. Early refills are not permitted as well unless there is an out-of-state emergency, and the client will be away for a prolonged amount of time may be an exception but not guaranteed.

Exception to Confidentiality:

The prescription provider has permission to discuss all diagnostic and treatment details with the dispensing pharmacist, among the laws enforced by the Drug Enforcement Agency (DEA), the Drug Control Division Act, the Pharmacy Practice Act, the State Food Drug and Cosmetic Act, and the State Controlled Substance Act. The Prescription Monitoring System (PMP) will be checked every visit in accordance with the Pharmacy Practice act and DEA. Any doctor shopping is grounds for immediate dismissal from the practice and the pharmacies, and prescribers will be alerted by the practice ensuring that you will not be able to get medications from the state or multi states in the future. This is deemed criminal behavior and you may be prosecuted in the state or states medications were obtained.

The Department of Consumer Protection and Drug Control Law and regulations or any other professionals who provide your healthcare for the purpose of maintaining accountability. If the responsible legal authorities' have questions concerning your treatment, which may occur, for example, if you were obtaining medications illicitly, obtaining needles from pharmacy or medications from multiple pharmacies, all confidentially is waived, and the authorities will be given full access to our records of controlled substance administration. 


Renewals are contingent with keeping your scheduled appointments. Prescriptions are contingent on monthly urine drug screening done 5 days prior to your visit and urine drug screen done in the office the day of your appointment. All urines will be sent to the lab for confirmation. Pill counts monthly in bottle from prescriber, and patients may be subject to random pill counts and random urine drug testing at any time during the year. 

If illicit drugs or the absence of prescribed is discovered via urine drug screen the client will adhere to a specific protocol for continued medication management if possible. If urine is found to be falsified (fake) from another person or under 97 degrees, or suspicious in any way, the client may be at risk of discharge. Patients may be subject to observed urines at specific labs or in office if questionable. Failure to produce a urine sample will lead to prescription to be held until urine is obtained for analysis. 

Protocol for any undesired behavior will necessitate a High-Risk Protocol (HRP) and weekly visits for 6-8 weeks (about 2 months) and referral to psychiatry, individual therapy, or in-patient rehabilitation services. Once behavior has been remedied then patient may earn bimonthly visits for a month then resume monthly visits. 

Please do not phone prescriptions and have your pharmacy fax a request to 203-481-5553 or an appropriate fax# at specific locations. 

Again, prescriptions will not be replaced if they are lost, stolen, wet, any other excuse without exception. Prescriptions will be refilled on an appropriate time schedule. Pt may go to the nearest hospital if needed and comfort medications will be given if needed. 

Any behavior that is deemed threatening, harassing, or disparaging to the provider will result in immediate discharge from the practice. Additionally, any arguing, yelling, swearing, texting, or calling the office more than two times is grounds for discharge. We get your message the first time. Our phones are checked frequently during the day M-Th 10:00-5:30 Fri 10-2. We do not check messages on the weekends or holidays. Do not text providers on their cell phones unless there is an extreme emergency that cannot wait or any thoughts of suicide. Provider cell phones are for patient calls and telehealth visits only. We will get back to you as soon as possible during business hours. If you are having a psychiatric or medical emergency, please call 911 or 211, or the suicide hotline immediately. 

Consequences of not adhering to this agreement: it is understood that failure to adhere to these policies may result in cessation of therapy with controlled substances, prescribing provider, or referral to psychiatry or a higher level of care.

Hold Harmless:

The patient and family of patient, agrees to hold harmless, not liable for, and releases the provider Dayna Giordano, and all providers under the group Dayna Giordano APRN, FNP-C and CT Pain, Addiction and Psychiatric Services, from any criminal or civil liability, criminal charges, or financial attachments from business or personal accounts during their course of treatment with all providers during treatment. This includes overuse of medications, accidental overdose, concomitant use of alcohol or other illicit substances or intended overdose of prescribed medications. Additionally, the client or family will not include any injury incurred during their course of treatment with providers, this includes but not limited to slips and falls or any other injury resulting from them. 

Payment and Medical Information Release Authorization:

Dayna Giordano is a medical provider and does not bill mental health insurance.

I hereby authorize direct payment of medical benefits to the provider, for services rendered by the provider or under their supervision. I understand that I am financially responsible for any balance not covered by my Insurance Company. Collection of any account balances past due three months after the billing date can and may be assigned to a collection agency.


Authorize to release information: I hereby authorize Dayna Giordano APRN to release any medical information necessary to process claims and determine benefits payable or not. Our assigned billing company will act as a secondary processor of claims and payments due on behalf of Dayna Giordano.

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Credit Card on File Agreement:

Due to the out-of-pocket expenses for services, Dayna Giordano, APRN requires that a credit card be kept on file. By signing this form, you authorize your credit card to be kept on file and charged on the day of service for any fees. In you have Insurance, you authorize your card to be charged for any fees not paid to Dayna Giordano, APRN. (e.g. copayments and deductibles) You may choose to pay by check at or before the date of service, and your credit card will NOT be charged for any services paid for by check. If payment is not made in full, or if payment arrangements are not made and kept, you understand that Dayan Giordano, APRN may turn your account over to a collection agency.

Medicare and Medicaid are NOT required to give CC#.

Authorization for credit card charge for no shows/cancellation policy.

By my signature below, I authorize Dayna Giordano, APRN to charge my credit card the amount identified for further state that I am the authorized signer for the credit card below.

Card Type

**Please note: There is a $150.00 no show fee and cancellation fee for all appointments not kept or cancelled within 24 hours prior to your appointment date unless there is some type of emergency. A credit/debit card number is required at the time of scheduling to secure all new patient appointments.

Have you ever had ECT?
Have you ever had Psychotherapy?
Do you have any drug allergies?
Do you currently have a primary care provider?
When was your last visit to your primary care provider?
Medical History (check all that apply):
Family History (check all that apply):
Tobacco Use (check all that apply):
Frequency of Tobacco Use:
Substance Abuse:
Alcohol Abuse:

In the past month, have you had any of the following problems?

Heart and Lungs:
Nervous System:
Women Only:
Kidney/Urine Bladder:
Stomach and Intestines:

Self-Pay Fee Schedule for Services:

  • Intake (Initial comprehensive first appointment only) $375

  • All follow up appointments (15-30 minutes) $200-225

I understand that self-paid sessions must be paid for on the date of service. I also understand that no-show fees may be charged $150 as missed follow-up appointments without at least 24 hours’ notice.

Release of Information (If Applicable):

I authorize the following using or disclosure party: Dayna Giordano, APRN

The above party may obtain/release this information to the following recipients:

  • I understand that I have the right to revoke this authorization, in writing, at any time except where uses or disclosure have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain information. To revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

  • I understand that uses and disclosures already made based upon my original permissions cannot be taken back.

  • I understand that it is possible that information used to be disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPPA AA Privacy Act.

  • I understand that treatment by any party may not be conditioned upon my signing of this authorization.

  • Unless treatment is sought only to create health information for a third party or to take part in a research study, I may have the right to refuse to sign this authorization.

  • A copy of this authorization is as valid as the original.

Thanks for submitting!

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