♦ Please print, fill out, and sign each form below and bring them to your first appointment ♦

If you are age 19 or older, bring “Demographics for Independent Adults” and if you are 18 or younger, bring “Demographics for Minors and Those with Guardians”

Declaration of Practices and Procedures

Notice of Privacy Practices

Summary of the HIPAA Privacy Rule

Demographics for Independent Adults

Demographics for Minors and Those with Guardians

Presenting Problems and Concerns

Insurance Verification_Payment for Services Contract

Credit Card Authorization Form

Referral Source Questionnaire

Mind Matters Map and Parking Instructions