Forms

TELEHEALTH FORMS:  Complete BOTH of the following consent forms before engaging in telehealth therapy:

E-Sign: Telehealth Informed Consent       -OR-        Print and Sign: Telehealth Informed Consent

E-Sign: Email and Text Consent                -OR-        Print and Sign:  E-Mail and Text Consent

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IN-PERSON FORM:  Compete this form before engaging in in-person therapy:

E-Sign:  In-Person Consent          -OR-          Print and Sign:  In-Person Consent

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

 

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

              E-Sign:  Child Paperwork              E-Sign:  Adult Paperwork                    E-Sign:  Paperwork

             E-Sign:  Family Inventory              E-Sign:  Family Inventory

 

- OR - Print the forms below, complete and sign, and bring them with you to your first visit.

          Print and Sign:  Child Forms         Print and Sign:  Adult Forms           Print and Sign Update Forms

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

E-Sign:  Release of Information      -OR-     Print and Sign: Release of Information

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DIVORCE CONSENT:  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:

E-Sign:  Divorced Parents Agreement     -OR-     Print and Sign: Divorced Parents Agreement

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ASSESSMENT AUTHORIZATION:  Complete this form to authorize psychological testing/assessments:

E-Sign:  Authorization for Assessment     -OR-     Print and Sign:  Authorization for Assessment

 

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PRIVACY NOTICE:  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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HANDOUTS:  Helpful guidelines:

Cognitive Development

Time-In Guidelines

Time-Out Guidelines

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Helpful Forms

Click here to view and print forms for your appointment.

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