Forms

Initial Registration & Updates

These forms are interactive. Select a form to download it. Then you can open the form in your PDF software such as Adobe Reader, fill in your information, save the PDF, and then email it to your therapist.

Client Profile Client Intake Form Client Intake Symptom Checklist Marital and Relationship Intake Checklist Insurance / Payment Information Form

Anxiety Screen - GAD7 Depression Screen - PHQ9 HIPAA Notice of Privacy Practices & Informed Consent HIPAA Notice of Privacy Rights (disclosure only, accompanies above form) Coaching Intake Packet

(Standard PDF - print, complete, bring with you)

Release of Confidential Information

Children's Forms

Child / Adolescent Questionnaire Form

Child Anxiety Screen (ages 8-15) - Child Child Anxiety Screen (ages 8-15) - Parent

Child Depression Screen (ages 8-17) - Child Child Depression Screen (ages 8-17) - Parent

Pediatric Speech-Language Pathology Forms

Speech and Language Evaluation Parent Questionnaire Food Inventory Preferences Consent to Release Private Information

Optional Forms (Standard PDF - print, complete, bring with you)

Parent ADHD Check List Parent ADHD Follow-Up Teacher ADHD Check List Teacher ADHD Follow-Up Life Change Stress Test

Self-Assessment Perfectionism Screening Test Anger Inventory Alcohol Use Disorders Identification Test (AUDIT) Drug Use Questionnaire Burnout Questionnaire

Psychological tests offered for a fee:

Gottman Relationship Checkup - $50

Developed from over 40 years of scientific research by Dr. John Gottman, this relationship assessment tool relies on intensive, detailed, and evidence-based information on why relationships succeed or fail.

SASSI-4 - $50

The SASSI instruments are self-report screening instruments that are designed to accurately identify adolescents and adults with a high probability of having a substance use disorder (SUD). These instruments help guide appropriate treatment and are useful in a variety of settings such as substance abuse treatment centers, criminal justice programs, behavioral health centers, social service programs, and other healthcare organizations.

PAI - $75

The Personality Assessment Inventory (PAI) provides information relevant for clinical diagnosis, treatment planning and screening for psychopathology.

NEO-PI-3 - $75

The NEO-PI-3 is the updated version of the Revised NEO Personality Inventory (NEO PI-R) – the standard questionnaire of the Five-Factor Model (FFM). It is a comprehensive measure of the five major domains of personality (Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness) and the six facets that define each domain. The NEO-PI-3 can be used in counseling and clinical settings with adolescents and adults, business and industrial settings, and for psychological research, including studies in sport psychology and recreation.

... and others - call us for more info.