Forms
 

In order for us to help you more efficiently and effectively, we would appreciate you providing us with some useful basic information. Below are new client forms. Click on the appropriate link, print out the PDFs by clicking on the printer icon at the upper left hand corner of the page (not your browser print command) and fill in the information prior to attending your first session. Otherwise, please arrive twenty minutes prior to your initial appointment to complete paperwork. Completing these ahead of time will prevent allotted counseling time having to be spent on filling out forms.

Please complete all child or adult forms unless noted. If you are 18 and older, please complete the adult forms. If the client is under 18, please have the parent/legal guardian complete the child forms.
 

Adult Forms

• Client Information, Insurance, Consent for Treatment and Financial Responsibility
  Reason for referral, history and symptoms
  Medication record
  Consent to release information to your primary care physician
  Consent to call you at work and/or at home
  HIPAA consent
  Medicaid (please complete this form if you have Medicaid)
   

Child Forms

• Child/Client Information, Insurance, Consent for Treatment and Financial Responsibility
  Reason for referral, history and symptoms
  Medication record
  Consent to release information to your primary care physician
  Consent to call you at work and/or at home
  HIPAA consent
  Medicaid (please complete this form if you have Medicaid)
   

Information only (you do not need to print the articles below)

• Cornerstone Psychological Services’ complete Health Insurance Portability and Accountability Act (HIPAA) policy
  Client’s Rights

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