Forms

English Forms

All forms in English : Intake, Consent, Rights & Responsibilities, etc. Both Printable and Digital.

Spanish Forms

Para los pacientes que forman parte de nuestra comunidad de habla hispana, envíenos un correo electrónico para obtener más instrucciones sobre cómo programarse. Un traductor puede estar disponible para usted si lo solicita.

 

English  Forms

 

Intake includes all required materials for Standard Evaluation.

Intake Adult

Intake Adolescent

Intake Child (13 & Under)

 

Special Evaluation forms for pain-related referrals are below. These are required in addition to the INTAKE forms above.

Pain

(Substance Abuse)

Pain Stimulator

(e.g., Spinal Cord Stimulator)

 

Separate copies of selected forms that are included in the intake materials are below.

Release

Primary Care Doctor

Release

Psychiatrist

Release

General Medical and All Others

HIPPA Consent

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Non-Discrimination Statement

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COVID Consent

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Telehealth Informed Consent

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Bariatric

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Advantage EAP (Employee Assistance Program)

Intake

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Rights and Responsibilities

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