Forms
Not Yet a Patient?
If you are interested in becoming a new patient, please complete the "Initial Intake Form" on the Home page under "Prospective Patient." 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. After receiving the form, one of our staff members will contact you.
First Time Patient Forms
If our office staff has contacted you and you have an appointment scheduled with our office please print and complete 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 complete the Child Forms. If the primary services will be provided to someone 19 years of age or older, please print, complete the Adult Forms.
Returning Patient Forms
If our office staff has contacted you and you have an appointment scheduled with our office, please print and complete the following forms prior to your first visit.
Divorce / Separated / Never Married 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:
Release Form
Complete this form to authorize release of psychotherapy information to/from other persons:
E-Sign: Release of Information
Assessment Authorization
Complete this form to authorize psychological testing/assessments:
Privacy Notice (HIPAA)
The Notice of Privacy Practices describes how psychological and medical information about you/your child may be used and disclosed: