Forms

At Family Therapeutics

we care for children, adolescents,

and adults individually

and as families.

At Family Therapeutics we are dedicated to preserving our environment.

Please review our Green Policy HERE.

Helpful Forms

All forms are available in Adobe Acrobat (.pdf) format

You can download the Adobe Acrobat reader free HERE

Visiting us for the first time?

To find out more about our practice, please

We like to give you every opportunity to recall important details of your past history. Completing paperwork in advance will always help to make your appointment as efficient as possible. All information submitted is confidential.

INITIAL EVALUATION PACKET

Please email us to obtain the initial evaluation packet

RELEASE OF INFORMATION FORM

(please complete and bring to initial appointment if you authorize us to contact any of your past treating clinicians)

Release of Information (1 page)

WHAT THE GOVERNMENT REQUIRES YOU TO KNOW ABOUT YOUR HEALTH INFORMATION

Our Privacy Practices (3 pages)

"Our Privacy Practices" Acknowledgement (1 page)

FINANCIAL FORMS

Please email to obtain a copy of the credit card authorization form

CLINICAL & INFORMATIONAL FORMS

FORMS FOR CHILDREN/ADOLESCENTS

ADHD & ODD (SNAP scale) (2 pages)

Parents and/or Teachers to complete

Child and Adolescent Psychiatry Screen (3 pages)

Parents and/or Teachers to complete

Child Mania Rating Scale (3 pages)

Parent to Complete (for Bipolar diagnosis)

Depression Scale (CES-DC) (2 pages)

Child to complete (Center for Epidemiological Studies)

Child and Adolescent Anxiety Screen (3 pages)

Child to complete (S.C.A.R.E.D. questionairre)

GROWTH CHARTS

Growth Chart, Boys Ages 2-20 (1 page)

Growth Chart, Girls Ages 2-20 (1 page)

FORMS FOR ADULTS

Adult ADHD Rating Scale (1 page)

(World Health Organization Screening Tool)
Depression Scale (CES-D) (1 page)

(Center for Epidemiological Studies Scale)

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