FORMS

Printable 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 PROCEDURE
(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 & All Others
 HIPAA Consent Non-discrimination Statement COVID Consent Telehealth Informed Consent

Advantage EAP (Employee Assistance Program)

INTAKE RIGHTS & RESPONSIBILITIES

Digital 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 PROCEDURE
(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 & All Others
 HIPAA Consent Non-discrimination Statement COVID Consent Telehealth Informed Consent

Advantage EAP (Employee Assistance Program)

INTAKE RIGHTS & RESPONSIBILITIES