Patient Forms
Intake forms provide important information to your provider. Please click on the appropriate form for your specific intake. The form will open in Adobe Sign for you to fill out, sign, and submit electronically to our administrative department. After filling out and signing and pressing SUBMIT, it will prompt you for your email address. Once you submit your email address, you will receive an email to the email account you provided for you to confirm your email address. Once you confirm, the form will be submitted and you will receive a copy of the paperwork.
Paperwork must be submitted 24 hours prior to your scheduled intake appointment. If paperwork for Psychiatric Intake appointments is not submitted prior to 24 hours, your appointment will be cancelled and you will need to reschedule. If you are having issues with opening the forms, please contact us.
Online
Adult Individual Therapy:
(Age 18+)
- ADULT THERAPY INTAKE PACKET - 2022 (Telehealth Consent included)
Child/Adolescent Individual Therapy:
(Ages 2-17)
- CHILD THERAPY INTAKE PACKET - 2022 (Telehealth Consent included)
Note* - Parents/guardians need to sign the consent form.
Note* - If there is a JOINT CUSTODY situation, both parents need to sign the consent form. Please see the Child Consent form below for additional parent signatures.
Couples Therapy:
- ADULT THERAPY INTAKE PACKET - 2022 (Telehealth Consent included)
Note* - Both partners need to fill out an Adult Therapy Packet
Adult Psychiatric Medication Management:
- ADULT PSYCHIATRIC MEDICATION MANAGEMENT INTAKE PACKET - 2022 (Telehealth Consent included)
Child/Adolescent Psychiatric Medication Management:
- CHILD PSYCHIATRIC MEDICATION MANAGEMENT PACKET (0-11 years old) (Telehealth Consent included)
- CHILD PSYCHIATRIC MEDICATION MANAGEMENT PACKET (12-17 years old) (Telehealth Consent included)
Additional Online Forms:
- COVID Consent Form
- Telehealth Consent Form (Required)
- Client Permission and Acknowledgement Form (Annual Consent Form)
- ROI (Release of Information) Form - Therapy
- ROI (Release of Information) Form - Medication Management
- River Valley Controlled Substance Agreement Form
- RULE 25 PACKET
- Safe Harbor Agreement - 2022
Printable
- Client Permission and Acknowledgement Form (Annual Consent Form)
- Credit Card Payment and Authorization Form
- ROI (Release of Information) Form - Therapy
- ROI (Release of Information Form) - Medication Management
- COVID Consent Form
- Controlled Substance Agreement
- Notice of Privacy Practices Form - 2022
- River Valley Pet Policy
- Telehealth Consent Form (Required)
- Psychological Testing Billing Agreement
- Psychological Evaluation with Testing Form
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