PRA

Please download, print and complete ALL forms if you are seeing a PRA Therapist (psychologist, social worker or professional counselor) SEE MD NAME FOR MD PAPERWORK – Please date forms to the date of your appointment. DO NOT PRINT DOUBLE SIDED

•  Therapist Intake Paperwork Please print and complete the forms prior to your scheduled appointment with one of our therapists. Please also print any release of information or other forms that may apply. Bring to initial appointment.

  7.10.19

Please print and complete the forms prior to the appointment if scheduled with Dr. David Benson. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Dr. Benson Practice Guidelines and Policy and Procedures Please print and review Dr. Benson's policy and procedures and Guidelines. Please sign last page and return to staff.
•  Dr. Benson Intake Paperwork Please print and complete all forms. Bring to first appointment. Please date forms for date of scheduled appointment.
•  Benson Parent Questionaire & Behavioral Checklist FOR PATIENTS 18 & UNDER ONLY - Please complete these forms and bring them to your initial appointment with Dr. Benson

Please print and complete the forms prior to the appointment if scheduled with Dr.Jason Chang. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Intake Forms - General Please complete all attached forms prior to your first appointment. Please date forms the date of your initial appointment.
•  Dr. Jason Chang Parent Questionnaire Please complete the attached questionnaire and bring to initial appointment.
•  Dr. Jason Chang Practice Guidelines and Policy and Procedures Please review and sign last page and bring to initial appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Robert Fabsik. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Dr. Fabsik Intake Forms Please print and complete forms - bring to initial appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Katherine Godfrey. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Intake Forms - General Please complete all attached forms prior to your first appointment. Please date forms the date of your initial appointment.
•  Dr. Godfrey Practice Guidelines and Policy and Procedures Please review Dr. Godfrey's guidelines and sign last page. Please bring to initial appointment.
•  Dr. Godfrey Parent Questionaire Please complete prior to initial appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Julie Gorman. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Dr. Julie Gorman Intake Paperwork Please print and complete forms - bring to initial appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Brian McFaul. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Dr. McFaul Intake Paperwork Please print and complete forms - bring to initial appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Shah Nawaz. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Dr. Nawaz Intake Paperwork Please print and complete forms - bring to initial appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Janeen Paul. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Dr. Janeen Paul Intake Paperwork Please print and complete all forms prior to your initial appointment. Please date the forms the date of your appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Emmanuel Perakis. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Dr. Emmanuel Perakis Intake Forms Please print and complete the forms prior to the appointment if scheduled with Dr. Emmanuel Perakis. Please also print any release of information or other forms that may apply. Bring to initial appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Steven Resis. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Dr. Resis Intake Paperwork Please print and complete forms - bring to initial appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Sandy Rhee. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Intake Paperwork Please print and complete all intake paperwork. Date the forms for the date you are scheduled for your initial evaluation.
•  Dr. Sandy Rhee Parent Questionnaire Please complete and bring to initial appointment.
•  Dr. Sandy Rhee Practice Guidelines and Policy and Procedures Please review Dr. Rhee's guidelines and sign last page. Bring to initial appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Kathryn Schoenbrod. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Dr. Schoenbrod Intake Paperwork Please print and complete forms - bring to initial appointment.

Please print and complete the forms prior to the appointment if scheduled with Dr. Christopher Womack. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Parent Questionaire - Dr. Womack Please complete the entire form prior to initial appointment.
•  Dr. Womack Guidelines and Policy and Procudures Please review information about Dr. Womack's practice and sign form on last page of packet.
•  Intake Paperwork Please print and complete all intake paperwork. Date the forms for the date you are scheduled for your initial evaluation.

Please print and complete the forms prior to the appointment if scheduled with Dr. Donna Woods. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED

•  Intake Paperwork Please print and complete all intake paperwork. Date the forms for the date you are scheduled for your initial evaluation.
•  Dr. Woods Parent Questionaire Please print and complete prior to initial evaluation with Dr. Woods.
•  Dr. Donna Woods Guidelines and Policy and Procedures Please review and sign last page of packet. Bring to initial visit.

Please also print any forms from the Additional Forms section, that apply.

•  Intake Form for Dr. Lipin

Please print and complete/sign forms. Therapist Policy and Procedure and Notice of Privacy Practices are for you to review and keep. Bring remaining forms to first appointment.

•  Client Information Form

  7/10/19
•  Consents and Authorizations Please print and sign both pages - please wait to date until you come in for your appointment. Patients 12 years of age or older must sign both forms. For patients under 18, both parents must give consent for treatment and sign both forms.

  11/2018
•  Credit Card Authorization Form Required for co-pays at time of service if guarantor is not present at appointment. This is helpful to have set up with teens/young adults.

  2019
•  Release of Information Form If you would like PRA to communicate with outside agencies, schools, or PCP – you will need one for each separate contact.

  7/2017
•  Exchange of Information Form If you want us to send your diagnosis and treatment plan to your PCP – This is an one time occurrence and does not authorize ongoing communication.

  2017
•  Therapist Policy and Procedures Please print and review for contacting your therapist
•  Notice of Privacy Practices Please print and review - this is yours to keep
•  Policy and Procedure Signature Page Please read through all policy and procedures and sign form. Bring with you to first appointment.

Please also print any forms from the Additional Forms section, that apply.

•  Dr. Zercher Parent Questionnaire For patients 18 & younger.

  2017

Print any that apply.

•  Client Information Form

  7/10/19
•  Consents and Authorizations Please print and sign both pages - please wait to date until you come in for your appointment. Patients 12 years of age or older must sign both forms. For patients under 18, both parents must give consent for treatment and sign both forms.

  11/2018
•  Credit Card Authorization Form Required for co-pays at time of service if guarantor is not present at appointment. This is helpful to have set up with teens/young adults.

  2019
•  Patient Rights/Notice of Privacy Practices This is for you to keep - no need to bring it into your first appointment

  11/18
•  Medical History Form Only print if you are seeing a Psychiatrist/MD

  5/2017
•  Release of Information Form If you would like PRA to communicate with outside agencies, schools, or PCP – you will need one for each separate contact.

  7/2017
•  Exchange of Information Form If you want us to send your diagnosis and treatment plan to your PCP – This is an one time occurrence and does not authorize ongoing communication.

  2017
•  Address Change Form
•  New Insurance Form Please complete this form for ALL clinicians you see and all family members impacting by change of insurance. We will also need a copy of your new insurance card.
•  Within PRA Release of Information To be used when authorizing communication between therapists/MD’s WITHIN PRA.
•  Request for copy of own personal Medical Records
•  Social Security Omit Policy

  2017
•  Alert Wellness Assessment – Adult (For United Healthcare -UHC/Optum only)
•  Alert Wellness Assessment – Youth (For United Healthcare -UHC/Optum only)

FOR PRA PERSONNEL ONLY

•  Intake Benefit Verification Form 2019 Updated Intake Form

  7.10.19
•  Drop Box