Adult New Patient Paperwork

Adult Form 01/14 Demographics

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    New Patient Demographics

Adult Form 02/14 Intake Procedures

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    Intake Procedures

Adult Form 03/14 Freedom of Choice Statement

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    Freedom of Choice Statement

Adult Form 04/14 Financial Responsibility & Release

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    Financial Responsibility & Release

Adult Form 05/14 Informed Consent

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    Informed Consent

Adult Form 06/14 Protected Health Information (PHI) Disclosure

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    Protected Health Information (PHI) Disclosure

Adult Form 07/14 Cancellation/ No Show Policy

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    Cancellation/No-Show Policy

Adult Form 10/14 DAST-10 Questionnaire

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    DAST-10 Questionnaire

  • The following is a list of questions concerning information about your potential involvement with drugs, excluding alcohol and tobacco, during the past 12 months. When the words “drug abuse” are used, they mean the use of prescribed or over-the-counter medications/drugs in excess of the directions and any non-medical use of drugs. The various classes of drugs may include: cannabis (e.g., marijuana, hash), solvents, tranquillizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcohol or tobacco. If you have difficulty with a statement, then choose the response that is mostly right. You may choose to answer or not answer any of the questions in this section.
  • Instructions for this form.

    Through these questions, please read the full question carefully. After reading the question, if you feel that the answer is "Yes" please indicate your answer with a 1 in the field. If you feel that the answer is "No" please indicate your answer with a 0 in the field.

Adult Form 11/14 Mood Disorders

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    Mood Disorders

  • Has there ever been a period of time when you were not your usual self and…

Adult Form 12/14 SBQR

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    Suicide Behaviors Questionnaire

Adult Form 13/14 PHQ-A

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    Patient Health Questionnaire

Adult Form 14/14 Encounter Form

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    Encounter Form