Evansville Psychiatric Associates
Complete Outpatient Mental Health Care
Experienced Professionals and Proven Methods Focus
Board Certified Child and Adolescent Psychiatry / Board Certified Adult Psychiatry / Psychological Testing / Professional Counseling Services / Registered Play Therapy / Confidential Care
Practice Forms
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Welcome letter for patients Important information about practice policies. |
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Registration and Consent to Treat All new patients/guarantors must provide these basic demographics and a physical signature. They must sign this Consent to Treat and basic explanation of policies before their first session and anytime they have a change in circumstances. |
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Authorization to Release Healthcare Information This form is necessary to send records to or from other health care providers. You can also give us permission to speak with others about your care with this form. |
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New Patient Child Assessment -Therapy For Parents to complete before a first appointment with one of our therapists. |
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Provider Referral Form For use by Physicians, Nurse Practitioner, Physician Assistants, Social Workers, Schools and other providers |
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New Patient Adult Assessment -Therapy For Patients to complete before a first appointment with one of our therapists. |
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New Patient Psychologist Intake Questionnaire Our psychologist requests that you complete this before your first appointment with him. |
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Parent Intake Form for ADHD evaluation of a child For Parents to complete before appointment with a therapist when workup is for suspected or rule-out ADHD |
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Happiness Tools Weekly Activity Log with Mood Monitoring |
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Telehealth Consent to Treat TeleHealth Consent to Treat/HIPPA/FRF |
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Student Activity Checklist Scales for teachers or caregivers to help evaluate children's behaviors associated with ADHD. Parents/Guardians may ask teachers or caregivers to complete these brief scales from different times of day. |
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New Patient Appointment Request form for Patients without Internet Access The preferred method of registration is through our website. This printable form is for use for those unable to use a computer or without internet access. Information is used to best match patients with providers clinically and financially. |
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ADHD Self-Report Scale (ASRS-v1.1) Symptoms Checklist For 12 years old and older self assessment of ADHD symptoms |
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Vanderbilt ADHD Diagnostic Parent Scale For parents to rate their children's symptoms |
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Patient Health Questionnaire (PHQ-9) Questionnaire for assessment of symptoms of depression |
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Generalized Anxiety Disorder Screen (GAD-7) Used for assessment of Anxiety |
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Credit Card Authorization Form To hold your credit card information for payment processing on your account complete the form and return. |