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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Adult New Patient Packet All of the printable new patient paperwork needed to get an adult (ages 18+) set up for care at our office. Driver's License and Insurance Card are also required. |
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Child New Patient Packet All of the printable new patient paperwork needed to get a child or teenager (ages 4-17) set up for care at our office. Adult (18+) signature, Driver's License, and Insurance Card are also required. |
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Registration and Consent to Treat Established patients/guarantors must provide these basic demographics and a physical signature annually, or 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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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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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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Provider Referral Form For use by Physicians, Nurse Practitioner, Physician Assistants, Social Workers, Schools and other providers. |