Terie Clement's New Patient Forms

 

Here are the forms you will need for your first appointment.  

What to do:
1)  Start by looking at the 2nd column 
2)  Select each of these forms as they apply to your situation.  
 #2:  CCNPS Patient Registration Form.  Complete one of these forms for each patient. Parent or guardian information is also required for those patients under the age of 18 years. If you are asking for Couples’ Therapy, then both members are listed on the same form. Be sure to bring in your insurance card(s) if you have insurance, or copies of the front and back of the cards.

3A or 3B: Family History. This form is for your therapist’s review and helps them understand your situation better. If you are unsure how to complete the form, ask your therapist to assist you during your appointment.

#5: Privacy Practices Notice and Consent.  (REQUIRED.  Keep first 2 pages, sign and return last page)

#6: Important Checklist for Insurance. (For your use, if you are using insurance). Listed are questions for you to ask your insurance carrier, as needed. This is done typically by calling the phone number on the back of your insurance card, or by looking at their website. This is to help make sure that your counseling is covered by your insurance, and to ensure that you know your benefits. 

#8: Fee Agreement. If you are not using insurance. Bring this with you to your appointment. 

There will be other form(s) to complete and/or sign when you meet with your therapist.

3) Click "Download" to download the forms to your computer. (Choosing the 'view' option might not work)
4)  Open the forms. They are in Adobe Reader  (PDF) format.
5)  Complete and sign the forms. Notes:  If the patient is between 13-17 years of age, we need signatures from the teenager and the parent/guardian. We can only provide services if the required forms are completed, signed and unaltered.
6)  Bring them in for your appointment.  

Thank you.
 

SelectionFile type iconFile nameDescriptionSizeRevisionTimeUser
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(REQUIRED) ALL PATIENTS   561k v. 1 May 19, 2017, 9:33 AM Douglas Chandler
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ALL ADULTS  350k v. 1 Feb 27, 2016, 7:26 PM Douglas Chandler
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ALL PATIENTS 17 YRS AND YOUNGER  360k v. 1 Feb 27, 2016, 2:27 PM Douglas Chandler
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REQUIRED. Sign and bring in 2 copies.  461k v. 1 May 19, 2017, 9:33 AM Douglas Chandler
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REQUIRED. ALL PATIENTS. Please sign and bring in bottom page.   254k v. 1 May 19, 2017, 9:33 AM Douglas Chandler
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ALL PATIENTS WITH INSURANCE. For you use.  268k v. 1 Feb 27, 2016, 2:49 PM Douglas Chandler
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TERIE WILL TELL YOU IF YOU NEED THIS FORM.  225k v. 1 Feb 27, 2016, 3:27 PM Douglas Chandler