FORMS

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Downloadable Forms

Before your first appointment please complete the following form.

You can download a copy or fill out our electronic form!

Patient Information Form

Parent Facilitator Form

Step 1 of 5

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Patient Information
Name*
First Middle Last
Date of Birth
Age
Gender
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Employer
Employer Name
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Social Security Number
Email
Spouse's Name
First Last

Party Responsible for Payment
**if other than the patient named above**
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Driver's License
Social Security

Insurance Information
Name
First Middle Last
Insured's Date of Birth
Insurance ID
Insured’s Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Group #
Phone
Authorization #
Start Date

In Case of Emergency Contact
Patient Name
First Middle Last
Emergency Contact
First Last
Relation to Patient
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Home Phone
Mobile Phone

Who is your primary care physician?
Do we have your permission to notify your PCP that you are coming for counseling?
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you see a psychiatrist?
Name of Psychiatrist
First Last
Medication Allergies
If any
List current medications
Dosage Frequency
Prescribing Physician
First Last
Initial

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