Forms1

CLINIC FORMS

Adult History Form

Child History Form

Adult Rating Scales

Child Rating Scales

Auth. to Release Confidential Info.

Consent to Release to Insurance Co.

INFORMED CONSENT FORMS

Mary Mikalson, MSSW

Mindy Haseleu, Psy.D.

Levy O'Brion, MS, LPC

Tanya Green, MSW, LCSW

Credit Card Forms

On File Credit Card Information

One Time Credit Card Information

The “ON-FILE” form is to be used if you want us to keep your credit card number on file.

The One-Time form is to be used if you want us to charge your card and then discard the form and not keep any information on file.