Prior to your first appointment, please complete the following forms:
Every new client looking to schedule an initial appointment should please complete ALL of the intake forms and the applicable Questionnaire below.
Personal Information Form: This is an electronic form gathering basic personal information.
Authorization for the Exchange of Information: This form requires information on other providers.
HIPAA Form: This form requires your electronic signature
Outpatient Services Contract: This form requires your electronic signature
Please complete the Questionnaire that applies to the client’s age range: for clients under 18, a parent or guardian should complete the Parent Questionnaire. For clients over 18, please complete the Adult Questionnaire yourself.
Parent Questionnaire: If you are the parent(s) of a child under the age of 18, please complete the parent questionnaire
Adult Questionnaire: If you are over 18 (and not a high school student) please complete the adult questionnaire
Cuestionario para los Padres: Si es padre (s) de un niño menor de 18 años, complete el cuestionario para padres
PRIOR TO YOUR INTAKE ASSESSMENT APPOINTMENT
Medical Screening: If possible, please have the client’s vision and hearing screened by their doctor prior to their intake appointment.
Documents: Please bring copies, not originals, of the following items (we will need to keep them, and you will likely want to have the originals). We are not able to make copies in our office of more than 5 pages of client documents. If you’d prefer to upload the documents do so by clicking here.
- A photograph of your child
- Past evaluations of your child (school, or private) where appropriate
- Any discharge summaries from past hospitalizations or partial hospitalizations.
- Copies of any IEPS or 504 Plans from the past two years, if appropriate
- If either you or your child has had any neurological injuries that have been treated, please have your medical provider clear you for testing, and provide us with any reports summarizing the injury and treatment.