Consent for Treatment: This form covers confidentiality and its limits and confirms that you give consent for us to treat you or your child.

HIPAA Notice: This form outlines the HIPAA law which protects patient information.

Intake Packet: This packet asks for basic contact information, insurance information, family make-up, present symptoms, and treatment history.

Electronic Payment AuthorizationThis page asks for a credit card to be placed on file so we can charge co-pays and no-show fees.  Even if your insurance does not require a co-pay, we ask that you provide this information so we can bill you for missed appointments.

Financial PolicyThis page outlines our finance policy and fee schedule.  It also includes our cancellation policy and the fees that will be charged for no-shows and late cancellations.

Adverse Childhood Experiences (ACES) Questionnaire: This questionnaire asks about adverse childhood experiences and provides your ACES score.  Research links ACES scores to various developmental outcomes.

Vanderbilt Parent Rating: This measure is for parents to rate the symptoms of their child.

Vanderbilt Teacher Rating: This measure is for teachers to report their observation of a child's behavior in the classroom.

Our office staff will be happy to assist you with the required documentation necessary to begin treatment with us.  If you have any questions contact us at 385-215-9084.

Intake Forms

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We believe in the preciousness of a chilD AND THE HEALING POWER OF FAMILY CONNECTIONS