Forms

The various forms we use in our office to create your personal file are available online through the links on this page. To save time, you may download these documents and fill them out in advance of your appointment. You may bring them with you at the time of your visit, or return them by email or fax. The information you enter on the forms becomes part of your confidential record, also called Protected Health Information (PHI). The forms we use are described below.

Intake Form

This form contains your demographic information (address, date of birth, phone, email) and information we need to submit claims to your insurance company.

Adult Clinical Questionnaire

The Adult Clinical Questionnaire asks you to provide information about why you are seeking counseling or other psychological services. It asks questions about your general emotional and physical health, pertinent history, how you are feeling now, and what concerns are most important to you. The questionnaire gives your doctor/therapist a head-start in understanding how to be of help to you.

Mature teenagers may also complete the Adult Form prior to their visit, and are encouraged to do so.

Child & Adolescent Clinical Questionnaire

The Child & Adolescent Clinical Questionnaire is intended to be completed by parents of children and adolescents for whom you are seeking counseling or other psychological services. Like the adult form, it asks you to provide information about why you are making an appointment for your child, her/his general emotional and physical health, pertinent history, and what about your child is of greatest concern to you. The questionnaire helps your doctor/therapist get a head-start on the evaluation and treatment planning process.

In addition to parents completing the Child & Adolescent Clinical Questionnaire, mature teenagers are invited to also complete the Adult Clinical Questionnaire (see above) in order to provide their own perspective for the doctor/therapist.

Developmental History Form

This form is used with chldren as part of the diagnostic evaluation for Attention Deficit Disorder (AD/HD) and other learning and behavior problems. It should be completed by an adult who has knowledge of the child's development from birth. You only need to complete The Developmental History Form if your doctor/therapist asks you in advance to do so. It is not part of the standard intake process.

Release of Information Form

The Release of Information Form give us permission to release your Protected Health Information to another person of your choosing. This is necessary if you want us to communicate with another health care provider, an attorney, or family member, for example.

HIPAA Disclosure

In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), this document describes how medical information about you, including that involving mental health treatment and psychological services may be used and disclosed, and how you can gain access to this information. It also explains our commitment to your confidentiality and the measures we take to secure your Protected Health Information (PHI).