Forms


INTAKE FORM:  If you want to become a new patient, complete the following form to start the intake process.  Completing this form DOES NOT guarantee that you will be accepted as a patient in our clinic. It is simply the first step of the intake process. Be sure to respond to ALL questions. One of our staff members will contact you, usually within a week of receiving the completed form.

                   Electronic:  Initial Intake Form     -OR-    Print:  Initial Intake Form

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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:

              Electronic:  Child Paperwork              Electronic:  Adult Paperwork                    Electronic:  Paperwork

              Electronic:  Family Inventory              Electronic:  Family Inventory

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

                Print:  Child Forms                                    Print:  Adult Forms                                         Print:  Update Forms

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

               Electronic:  Telehealth Informed Consent       -OR-        Print:  Telehealth Informed Consent

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

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

               Electronic:  In-Person Consent          -OR-          Print:  In-Person Consent

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

               Electronic:  Release of Information      -OR-     Print:  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:

               Electronic:  Divorced Parents Agreement     -OR-     Print:  Divorced Parents Agreement

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

               Electronic:  Authorization for Assessment     -OR-     Print:  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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