Client Forms

Elaine will guide you to which forms clients will need to print and fill out. You will need Adobe Acrobat to download the following forms (all except forms 12 & 13 which are Excel documents). Most computers will have this program but if you do not please download here.

1.
Appointment and Referral Form
2.
Information Sheet
3.
Consent to Treatment
4.
HIPAA Notice of Privacy Practices
5.
Health Insurance Form (HCFA 1500)
6.
Couple Therapy Agreement
  6a.  Couple Therapy Questionnaire 1
  6b.  Couple Therapy Questionnaire 2
7.
Beck Depression Inventory
8.
Depression Self-Rating Scale
9.
Mood Disorder Questionnaire
10.
Child Behavior Checklist
11.
Caffeine Consumption Questionnaire
12.
Male Prism Chart (Excel worksheet)
13.
Female Prism Chart (Excel worksheet)
14.
Authorization for Exchange – Release of Information
15.
Suicide Prevention Contract