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Notice of Privacy Practices Form

Notice of Privacy Practices

Notice of Privacy Practices Form

Notice of Privacy Practices Form

Receipt of Notice of Privacy Practices

Name [please print]:
MM slash DD slash YYYY
Name [please print]:
Relationship to Patient:
Parent
MM slash DD slash YYYY

HIPAA Release Form

HIPAA Release Form

Patient Name:
MM slash DD slash YYYY
Current Address:
Street Address
City
MM slash DD slash YYYY

Welcome Letter with Treatment Consent

Welcome Letter with Treatment Consent

Treatment Consent Form

Treatment Consent Form

Consent Form

Name
Address
Max. file size: 512 MB.

Credit CArd Information

Credit Card Form

Credit Card

Patient Name:
MM slash DD slash YYYY
MM slash DD slash YYYY

Patient Demographic Information

Electronic Communication Consent Form

NEW PATIENT SCREENING FORM

Electronic Communication Consent Form

I consent to the use of mobile phone communications.
I consent to the use of texting (messages) communications.
I consent to receive electronic notifications for confirming, rescheduling or cancelling my appointments.
I consent to receive electronic notifications for confirming, rescheduling or cancelling my appointments.
MM slash DD slash YYYY

Electronic Communication Consent Form

NEW PATIENT SCREENING FORM

Electronic Communication Consent Form

I consent to the use of mobile phone communications.
I consent to the use of texting (messages) communications.
I consent to receive electronic notifications for confirming, rescheduling or cancelling my appointments.
I consent to receive electronic notifications for confirming, rescheduling or cancelling my appointments.
MM slash DD slash YYYY
Notice of Privacy Practices
Receipt of Notice of Privacy Practices
HIPAA Release Form
Welcome Letter with Treatment Consent
Credit Card information
Patient Demographic Information
Electronic Communication Consent Form

Booking Form

Booking

Name
Address

Documentation Form

Name
Address
Max. file size: 512 MB.

New Patient Screening Form

Electronic Communication Consent Form

I consent to the use of mobile phone communications.
I consent to the use of texting (messages) communications.
I consent to receive electronic notifications for confirming, rescheduling or cancelling my appointments.
I consent to receive electronic notifications for confirming, rescheduling or cancelling my appointments.
MM slash DD slash YYYY

Credit Card form

Credit Card

Patient Name:
MM slash DD slash YYYY
MM slash DD slash YYYY

HIPAA Release Form

HIPAA Release Form

Patient Name:
MM slash DD slash YYYY
Current Address:
Street Address
City
MM slash DD slash YYYY

Receipt of Notice of Privacy Practices Form

Receipt of Notice of Privacy Practices

Name [please print]:
MM slash DD slash YYYY
Name [please print]:
Relationship to Patient:
Parent
MM slash DD slash YYYY

New Patient Screening

New Patient

1. Have you had any suicide attempts within the last 2 years?
2. Have you been psychiatrically hospitalized within the last 2 years?
3. Have you recently been discharged from a Partial Hospital Program (PHP) or Intensive Outpatient Program (IOP)?
4. Have you struggled with substance abuse or dependence within the last year?
5. Have you ever attended rehab or detox?
6. Do you have any current legal problems that would require our involvement?
7. Is this evaluation for getting psychiatric disability from work?
8. Have you been hospitalized for seeing things, hearing things, or believing strange things?
9. Have you ever intentionally injured someone else?
10. Are you currently taking any opioids (i.e., Percocet, Oxycodone, Oxycontin, Morphine, or Dilaudid)?
11. Are you currently taking any benzodiazepines (I.e., Klonopin, Ativan, Valium, Xanax or Temazepam)?