PRA

Please download, print and complete each form – Please do not date the forms, we will date them on the day of your visit.

•  Client Information Form

  11/2018
•  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 Helpful to have set up with teens or other patients for copays.

  2014
•  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

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

•  Parent Questionnaire For patients 18 & younger.
•  Practice Guidelines for Dr. Woods Only if you are seeing Dr. Woods
•  Behavioral Checklist For patients 18 & younger.
•  Introduction Letter for Dr. Woods For patients 18 & younger.

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

•  Parent Questionnaire For patients 18 & younger.
•  Practice Guidelines for Dr. Womack Only if you are seeing Dr. Womack.
•  Introduction Letter for Dr. Womack For patients 18 & younger.

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

•  Parent Questionnaire For patients 18 & younger.
•  Practice Guidelines for Dr. Godfrey Only if you are seeing Dr. Godfrey.
•  Introduction Letter for Dr. Godfrey For patients 18 & younger.

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

•  Practice Guidelines for Dr. Chang Only if you are seeing Dr. Chang.
•  Introduction Letter for Dr. Chang For patients 18 & younger.
•  Parent Questionaire - Chang Parent Questionnaire

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

•  Parent Questionnaire For patients 18 & younger.
•  Behavioral Checklist For patients 18 & younger.
•  Practice Guidelines for Dr. Rhee Only if you are seeing Dr. Rhee
•  Introduction Letter for Dr. Rhee For Patients 18 & younger

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

•  Client Information Form

  11/2018
•  Yoga Therapy/Classes Agreement and Liability Release (For Therapy and Classes.
•  Health Form for Yoga and Meditation Classes

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

•  Intake Form for Dr. Lipin

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.

•  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
•  Address Change Form
•  New Insurance Form We will also need a copy of your new insurance card.
•  Charge Card Form If you would like us to keep your charge number on file.
•  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)

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

•  Intake Benefit Verification Form 2019 Updated Intake Form

  11/2018
•  Drop Box