New Client Forms

New clients are required to review and sign certain forms prior to or at the time of their initial appointment.

You may obtain this information and the admission forms prior to your initial appointment by downloading and printing the forms below. You must bring the forms you are required to sign or complete with you to your initial appointment. If you do not wish to review and download these forms now, you may arrive 30 minutes early to your initial appointment and complete them at that time.


(Please review the instructions below and click on the forms to download and print.)

New clients are required to review our Financial Policy & Fees 2013, Notice of Privacy 2013, and Client’s Rights & Grievance Procedure. These forms are for your review, you do not need to bring them to your initial appointment.

In order to give your psychiatrist or psychotherapist some background information about your problems, all new clients are asked to complete a history form. Adults and older adolescents are asked to complete the Family History Form. Parents/guardians of children and adolescents who are seeking treatment are asked to complete the Child Adolescent History Form.  Please bring these forms with you to the initial appointment.

Finally, we require all new clients to complete and sign the following forms as part of our admission process. The following must be brought to the initial appointment:
 

Patient Registration Form (this insures we have accurate demographic and insurance information)
Consent to Treatment (this form authorizes your consent to treatment and also allows us to bill your insurance company if applicable)
Privacy Notice Acknowledgement (we are required by law to verify that you have received and reviewed our privacy notice)
Primary Care Collaboration Form (this form allows us to collaborate with your primary care physician or your child’s pediatrician about treatment)

 

 

Which forms do I bring to my initial appointment?
The following checklist of the above forms should be completed, signed and brought to your initial appointment:

 

 

• Family History Form (or) Child & Adolescent History Form
• Patient Registration Form
• Consent to Treatment
• Privacy Notice Acknowledgement
• Primary Care Collaboration Form

 



Comprehensive Counseling is covered by most insurance plans.
For more information, call our clinic at 262-284-5789.