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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
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