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 Evaluation / 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 about your care, schedule appointments, or manage billing with others via this form. |
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New Patient Adult Assessment -Therapy An initial assessment for patients to complete before a first appointment with one of our therapists. |
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Adult Mental Health Rating Scales To rate symptoms of anxiety, depression, ADHD, and more. |
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New Patient Child Assessment -Therapy An initial assessment for children to complete before a first appointment with one of our therapists. |
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Child Mental Health Rating Scales To rate symptoms of anxiety, depression, ADHD, and more in children. |
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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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Credit Card Authorization Form To hold your credit card information for payment processing on your account, complete the form and return. |
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Provider Referral Form For use by Physicians, Nurse Practitioner, Physician Assistants, Social Workers, Schools and other providers. |