Patient FormsDerek Judkins2019-06-16T12:58:49-05:00 Patient FormsClick on the orange form title to open or download.Release of Information Electronic Releases Mental Health Authorization Substance Use Disorder Authorization Primary Care Provider Authorization Psychiatry Primary Care Provider Authorization Printable Releases Mental Health Authorization Substance Use Disorder Authorization Primary Care Provider Authorization Psychiatry Primary Care Provider Authorization Outpatient Psychiatric Medication Management Adult Psychiatry Medication Management - NEW PATIENT FORMS Child Psychiatry Medication Management - NEW PATIENT FORMS Primary Care Provider to Release Information for Psychiatry Tele-Psychiatry Consent Form Adult Psychiatry Intake Packet – PDF file Child/Adolescent Psychiatry Intake Packet – PDF file Psychological Evaluation Mental Health Evaluation/Testing Consent and Information Form ADD/ADHD Non-Covered Testing Agreement (BCBS) Child/Adolescent Testing Intake Packet Adult Testing Intake Packet Adult Rehabilitative Mental Health Services (ARMHS) Rights and Responsibilities Children's Therapeutic Services and Supports (CTSS) Rights and Responsibilities Child and Adolescent Assessment for Caregiver Adult Day Treatment (ADT) Client Contact Information Medication List PHQ9 Nutrition Counseling Services Intake Packet 18+ Intake Packet 13-17 Intake Packet 12 & Under Adult Nutrition Screening Questionnaire (18+) Adolescent Nutrition Screening Questionnaire (13-17) Child Nutrition Screening Questionnaire (12 & Under) General Forms Patient Rights Handout Notice of Privacy Practices Fee Agreement Notice of Nondiscrimination
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