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 (or their guarantors) are asked to fill out these basic demographics for a physical signnature and to 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. |
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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. |