FORMS AND RESOURCES
Patient Forms
New Patient Packets - Choose the age bracket of the patient to open the appropriate forms to print and fill-out.
Please remember to take your completed forms and arrive at least 15 minutes prior to your first visit.
- Adults (Age 18+ years old)
- Adult Patient Registration (English) (Spanish)
- Adult Intake Assessment (English) (Spanish)
- Notice of Patient’s Rights and Responsibilities, and Privacy Practices as required by the Health Insurance Portability and Accountability Act (HIPAA) OF 1996 (English & Spanish)
- Acknowledgement regarding Cancelled and Missed Appointments (English & Spanish)
- Adolescents (Age 13-17 years old)
- Child/Adolescent Patient Registration (English) (Spanish)
- Psychosocial History for Children/Adolescents (English & Spanish)
- About Myself
- Notice of Patient’s Rights and Responsibilities, and Privacy Practices as required by the Health Insurance Portability and Accountability Act (HIPAA) OF 1996 (English & Spanish)
- Acknowledgement regarding Cancelled and Missed Appointments (English & Spanish)
- Children (5-12 years old)
- Child/Adolescent Patient Registration (English) (Spanish)
- Psychosocial History for Children/Adolescents (English & Spanish)
- Notice of Patient’s Rights and Responsibilities, and Privacy Practices as required by the Health Insurance Portability and Accountability Act (HIPAA) OF 1996 (English & Spanish)
- Acknowledgement regarding Cancelled and Missed Appointments (English & Spanish)
- Patient Guide (English) (Spanish)
- Coordination of Insurance Benefits (English & Spanish)
- Release of Information Authorization (English & Spanish)
Screening Tools – These are not intended to replace professional clinical judgement. CONSULT A PROFESSIONAL CLINICIAN for proper diagnosis.
- ADHD Screening
- ADHD School Questionnaire
- ADHD Classroom Questionnaire
- Depression Questionnaire
- Depression Screening Tool
- Gambling Screening Tool
- AUDIT Questionnaire
- CAGE-AID Questionnaire
- CRAFFT Questionnaire
Provider Forms
Network Enrollment
Clinical Forms
- Initial Mental Health Assessment
- SED/SMI Determination
- Outpatient Extended Care
- Request for Testing
- Treatment Referral
Psychiatrist/MD/DO or Psychiatric Physician’s Assistant