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Green Hills with Blue Sky

Forms

If you have been accepted as a new patient:  print, complete, and sign the following forms and bring them to your first visit. If the primary focus of the service is for a child/youth under 19 years of age, please complete and sign all "Child Forms."  If the primary services will be provided to someone 19 or older, please complete and sign all "Adult Forms."  If you are a patient returning to clinic after a year or more, please complete and sign all "Update Forms."

 

          Forms for Child Patient:               Forms for Adult Patient:               Forms for Returning Patient:

                 Child Forms                                Adult Forms                                 Update Forms

 

 

Complete this authorization form to authorize release of psychotherapy information to/from other persons:

Release of Information
 

If parents/guardians are separated or divorced, the Agreement for Child Psychotherapy with Separated or Divorced Parents/Guardians is to be signed by both parents/guardians:

Divorced Parents Agreement

 

The Notice of Privacy Practices describes how psychological and medical information about you/your child may be used and disclosed:

Notice of Privacy Practices

 


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Helpful Forms

Click here to view and print forms for your appointment.

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