If you are a new or returning patient to our practice, please print and complete the following forms, and bring them to the first appointment. Additionally, be sure to bring photo identification, insurance card(s), and any pertinent medical records or referrals for service.

• Registration Form
• Professional Service Agreement
• Insurance Release
• Credit Card Authorization
• Health History Questionnaire
• HIPAA Acknowledgement*

* First review the Patient Records Privacy Policies And Procedures

To coordinate care with another provider (for example, psychiatrist, primary care physician, etc.), complete this form to authorize release of information.
 

• Authorization To Release Protected Information

If you have been referred for a Fitness For Duty Evaluation, please print and complete the following form, and bring it to the appointment. Be sure to bring photo identification and any pertinent medical, employment, legal, or academic  records that you have been asked to produce. 
 

• Fitness For Duty Evaluation Informed Consent Contract  

If you have been referred for a Forensic Evaluation, please print and complete the following form, and bring it to the appointment. Be sure to bring photo identification and any pertinent medical, employment, legal, or academic records that you have been asked to produce.

• Forensic Evaluation Informed Consent Contract

Note: To download Adobe Acrobat Reader for free, click here.

If you have any questions about the above forms or any concerns in advance of your appointment, please contact us by using the form below or call our office at 847.696.1100.

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