Patient Forms

Please complete the following online forms:

1. Health History Form  - Adult
2. Health History Form - Child
3. Client Information & Communications Agreement
4. Consent to Receive Services/Confidentiality/Payment Agreement
5. Release of Information
6. Release for Court Testimony
7. Telemental Health Consent

Telehealth: Please submit forms within 12 hours of your first appointment. Without these forms, your Telehealth appointment will need to be rescheduled.

In-office appointments: COVID-19 Hold Harmless Disclosure

Give us a call or email if you have questions about which forms are needed.

Haga clic aquí para obtener formularios para pacientes.

We value your feedback and invite you to complete a brief feedback form about your experience. 

When you want your clinician at APS to share your protected health information (PHI), you need to complete a  Release of Information form (sometimes called an "ROI"). The ROI you provide tells your clinician how/to whom they may share your information (your PHI). 

Protected Health Information (PHI) includes:

• Your Evaluation Report and Findings
• Your Mental Health Diagnoses
• Your Treatment Summaries
• Your Treatment Recommendations

The Release of Information agreement is needed for the APS clinician to share your protected health information (PHI) with others. 

You may want your clinician to communicate with one or more of the following:

• Healthcare providers (Pediatrician, Psychiatrist, Surgeon, Psychologist, Therapist) 
• Court officials (Probation Officer, Attorney, Judge) 
• Agencies (DFCS, DJJ, Social Security, Police)
• Schools, Teachers, or Guidance Counselors
• Treatment Center,  Healthcare Practice, Hospital

Click below if you are ready to complete the Release of Information form for your APS clinician.