Acknowledgment of Policies and Agreement Form
Authorization for Release of Information Form
Voicemail/Text Message/Email Consent Form
Referral for Services Form
Client Satisfaction Survey
Agreement for Safe & Effective Controlled Substance Prescription
Patient Consent for Telehealth TX and Services
Email, SMS Messaging & Telehealth Consent
Consent For Release of Patient Information
Patient Agreement of Financial Responsibility
Forms to Expect on Your Patient Portal
- Client History Form: This form requests information about the presenting issue and relevant biopsychosocial history from the patient.
- Client Information Form: This form requests name, address, contact info, gender, and more from the patient.
- Client Insurance Form: This form requests insurance information from the patient.
- Emergency & Other Contacts Form: This form requests information for patient contacts such as primary care physician and emergency contacts.
- Consent for Services: This form requests signed acknowledgement of your consent for services.
- Notice of Privacy Practices: This form requests signed acknowledgement of your notice of privacy practices.
- Payment Authorization Form: This form requests and authorizes credit card information and has the patient sign an authorization for payment.
- Release of Information: This form requests authorization from the patient to release information to a specified contact.
To view other forms, please visit our patient portal.
Patient Portal