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Green Hills with Blue Sky

Forms

If you have been accepted as a new patient, print and complete the following forms and bring them to your first visit. Please note, there are separate forms for adults and children.  If the primary focus of the service is for a child/youth under 19 years of age, please complete all four child documents.  If the primary services will be provided to someone 19 or older, please complete all four adult documents. 

 

          Primary Focus: Child                           Primary Focus: Adult

          Intake Form                                       Intake Form

            Office Policy                                             Office Policy

            Client Consent                                         Client Consent

            Child Inventory                                        Adult Inventory

            Informed Consent                                   Informed Consent

 

 

 

Complete the Authorization Form to authorize release of psychotherapy information to other persons, such as your psychiatrist, school, etc.:

Authorization Form
 

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

 


Note: To download Adobe Acrobat Reader for free, click here.

Helpful Forms

Click here to view and print forms for your appointment.

CLICK HERE