NOT YET A PATIENT? If you are interested in becoming 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.
Initial Intake Form (CHILD PATIENT) -OR- Initial Intake Form (ADULT PATIENT)
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FIRST TIME PATIENT FORMS: If you have an appointment scheduled with our office: 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 complete the Child Paperwork and Family Inventory under the "Forms for Child Patient." If the primary services will be provided to someone 19 years of age or older, please complete the Adult Paperwork and Family Inventory under the "Forms for Adult Patient." If you are a patient returning to clinic after six months or more, please complete the Paperwork under the "Forms for Returning Patient."
Forms for Child Patient: Forms for Adult Patient: Forms for Returning Patient: (Complete Both Forms) (Complete Both Forms)
Electronic: Child Paperwork Electronic: Adult Paperwork Electronic: Returning Paperwork
- OR - Print the forms below, complete and sign, and bring them with
you to your first visit.
Print: Child Forms Print: Adult Forms Print: Returning Forms
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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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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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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 (HIPAA): The Notice of Privacy Practices describes how psychological and medical information about you/your child may be used and disclosed:
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HANDOUTS: Helpful guidelines:
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