Forms

The following are REQUIRED FORMS AND MUST BE COMPLETED BY ALL PATIENTS (A TOTAL OF Eight Forms Must Be Completed)

Alcohol/Drug Intake (Required For ALL Drug/Alcohol Services):

• Alcohol/Drug Assessment Intake Form
• Consent Form
• Release of Information Form
• Financial Policy
• Insured/Responsible Party Information
• Notice of Privacy Practices
• Office Policies
• Patient Record of Disclosures
• WHODAS Assessment Form
• Expectations for Group Members (pdf)

Adult Intake (Required For ALL NON Alcohol/Drug Services For Ages 18 years old & Up):

• Adult Intake
• Consent Form
• Release of Information Form
• Financial Policy
• Insured/Responsible Party Information
• Notice of Privacy Practices
• Office Policies
• Patient Record of Disclosures
• WHODAS Assessment Form

Child/Adolescent Intake (Required For Ages 4 -18 years old  ONLY):

• Child and Adolescent Intake and Behavioral Checklist
• Consent Form
• Release of Information Form
• Financial Policy
• Insured/Responsible Party Information
• Notice of Privacy Practices
• Office Policies
• Patient Record of Disclosures

Gastric Bypass Questionnaire

• Gastric Bypass Questionnaire

Additional Forms:

• Credit Card Authorization Form (pdf)