Completed new patient paperwork is required at the initial appointment for EACH PRA clinician that you see. Our paperwork serves as consent to treatment and there must be one on file for each clinician you see at PRA. All forms to be completed for your initial appointment are available below. If you are seeing a THERAPIST, click New THERAPIST Patient Paperwork. If you are seeing one of our psychiatrists/MD’s – Click all the listed forms under their name.
DROP BOX AND HOW TO GET YOUR FORMS TO PRA click to expand/collapse
DROP BOX IS A HIPAA COMPLIANT WAY TO SEND DOCUMENTS TO OFFICE STAFF AT PRA. SAVE YOUR DOCUMENT WITH YOUR FULL NAME, HIT DROP BOX LINK, PICK THE STAFF PERSON YOU WANT TO SEND IT TO AND THEN FIND YOUR DOCUMENT THEN UPLOAD. SEE INSTRUCTIONS.
IN OFFICE SESSION CONSENT FORM AND EXPECTATIONS click to expand/collapse
IN PERSON OFFICE SESSION GUIDELINES DURING COVID-19
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INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 CRISIS PLEASE COMPLETE IF IT IS YOUR FIRST SESSION AT PRA IS IN PERSON - THIS FORM IS FILLABLE - PLEASE COMPLETE, PRINT AND SIGN NAME. YOU CAN DROP BOX IT TO THE OFFICE OR BRING IT IN ON YOUR FIRST TIME IN THE OFFICE. TO DROP BOX - FILL FORM OUT COMPLETELY, FILE - SAVE AS- WITH YOUR NAME ON IT AND THEN GO TO PRA FORMS, HIT DROP BOX AND YOU CAN SEND THE FORM TO OFFICE STAFF.11/2020
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OFFICE SAFETY PRECAUTIONS IN EFFECT DURING THE PANDEMIC THIS IS FOR YOU TO KEEP - THIS OUTLINES PRA SAFETY MEASURES FOR IN PERSON APPOINTMENTS-
NEW PATIENT PAPERWORK - FOR YOUR PSYCHIATRIST/PHYSICIAN/NURSE PRACTIONER VISIT click to expand/collapse
IF USING FILLABLE FORM, SAVE THE FORM AS YOUR FULL NAME, AFTER COMPLETING, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! PRINT ALL FORMS AS INDICATED WHEN MAKING APPOINTMENT
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CLIENT INFORMATION FORM - FILLABLE AFTER COMPLETING THE FORM, SAVE AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! COMPLETE ALL SECTIONS. THANK YOU!09/21
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Consents and Authorizations - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! 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.11/2020
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MEDICAL HISTORY FORM - FILLABLE SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! PLEASE COMPLETE ALL ASPECTS OF THIS FORM3/2020
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Credit Card Authorization Form - Fillable AFTER COMPLETING - USE SAVE AS FUNCTION AND SAVE IT WITH YOUR NAME, OTHERWISE IT WILL COME TO US BLANK!!! Form is fillable. Please make sure to list name of Cardholder on the form.01/2022
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POLICY AND PROCEDURES - MD'S PLEASE REVIEW DOCUMENT - THIS FORM IS YOURS TO KEEP-
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POLICY SIGNATURE PAGE - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! PLEASE SIGN AND RETURN AFTER READING THROUGH ALL POLICIES-
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Exchange of Information Form - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! 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.3.24.20
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Release of Information Form - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! If you would like PRA to communicate with outside agencies, schools, or PCP – you will need one for each separate contact.2020
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Notice of Privacy Practices This is for you to keep and does not need to be turned in.1.24.20
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TELEHEALTH CONSENT FORM PLEASE SIGN AND RETURN PRIOR TO YOUR FIRST TELEHEALTH -FILLABLE FORM. SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!!11/2020
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INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 CRISIS PLEASE COMPLETE IF IT IS YOUR FIRST SESSION AT PRA IS IN PERSON - THIS FORM IS FILLABLE - PLEASE COMPLETE, PRINT AND SIGN NAME. YOU CAN DROP BOX IT TO THE OFFICE OR BRING IT IN ON YOUR FIRST TIME IN THE OFFICE. TO DROP BOX - FILL FORM OUT COMPLETELY, FILE - SAVE AS- WITH YOUR NAME ON IT AND THEN GO TO PRA FORMS, HIT DROP BOX AND YOU CAN SEND THE FORM TO OFFICE STAFF.11/2020
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OFFICE SAFETY PRECAUTIONS IN EFFECT DURING THE PANDEMIC THIS IS FOR YOU TO KEEP - THIS OUTLINES PRA SAFETY MEASURES FOR IN PERSON APPOINTMENTS-
NEW PATIENT PAPERWORK - FOR YOUR THERAPIST SESSION click to expand/collapse
IF USING FILLABLE FORM, YOU MUST SAVE THE FORM AFTER COMPLETING BEFORE SENDING TO OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! PRINT ALL FORMS AS INDICATED WHEN MAKING APPOINTMENT
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CLIENT INFORMATION FORM - FILLABLE AFTER COMPLETING THE FORM, SAVE AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! COMPLETE ALL SECTIONS. THANK YOU!09/21
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Consents and Authorizations - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! 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.11/2020
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Credit Card Authorization Form - Fillable AFTER COMPLETING - USE SAVE AS FUNCTION AND SAVE IT WITH YOUR NAME, OTHERWISE IT WILL COME TO US BLANK!!! Form is fillable. Please make sure to list name of Cardholder on the form.01/2022
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Therapist Policy and Procedures Please print and review for contacting your therapist3.23.20
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POLICY SIGNATURE PAGE - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! PLEASE SIGN AND RETURN AFTER READING THROUGH ALL POLICIES-
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Exchange of Information Form - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! 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.3.24.20
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Release of Information Form - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! If you would like PRA to communicate with outside agencies, schools, or PCP – you will need one for each separate contact.2020
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Notice of Privacy Practices This is for you to keep and does not need to be turned in.1.24.20
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TELEHEALTH CONSENT FORM PLEASE SIGN AND RETURN PRIOR TO YOUR FIRST TELEHEALTH -FILLABLE FORM. SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!!11/2020
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INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 CRISIS PLEASE COMPLETE IF IT IS YOUR FIRST SESSION AT PRA IS IN PERSON - THIS FORM IS FILLABLE - PLEASE COMPLETE, PRINT AND SIGN NAME. YOU CAN DROP BOX IT TO THE OFFICE OR BRING IT IN ON YOUR FIRST TIME IN THE OFFICE. TO DROP BOX - FILL FORM OUT COMPLETELY, FILE - SAVE AS- WITH YOUR NAME ON IT AND THEN GO TO PRA FORMS, HIT DROP BOX AND YOU CAN SEND THE FORM TO OFFICE STAFF.11/2020
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OFFICE SAFETY PRECAUTIONS IN EFFECT DURING THE PANDEMIC THIS IS FOR YOU TO KEEP - THIS OUTLINES PRA SAFETY MEASURES FOR IN PERSON APPOINTMENTS-
TELEHEALTH FORMS click to expand/collapse
TELEHEALTH CONSENTS AND OTHER INFORMATION
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TELEHEALTH CONSENT FORM PLEASE SIGN AND RETURN PRIOR TO YOUR FIRST TELEHEALTH -FILLABLE FORM. SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!!11/2020
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TELEHEALTH - CHECKING INTO YOUR SESSION GUIDE OF HOW TO SIGN IN FOR YOUR VIRTUAL VISIT3.18.20
For Angela Astleford, PMHNP NEW Patients - ADDITIONAL PAPERWORK click to expand/collapse
FOR PATIENTS 13 - 17 years of age, please complete the Parent Questionaire and Behavioral Checklist. ALL PATIENTS please complete PHQ9 and GAD7 - please note if insurance does not cover these two assessment, you will be responsible for no more than $10 total. POLICY AND PROCEDURE - REVIEW AND KEEP AS REFERENCE.
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Parent Questionaire and Behavioral Checklist - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! Please complete both forms prior to the patients first appointment.3.24.20
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PHQ9 AND GAD7 ASSESSMENTS Please have these additional forms completed prior to your first appointment. Forms are fillable - once completed in adobe, SAVE AS and rename document with patient name.-
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ANGELA ASTLEFORD POLICY AND PROCEDURES PLEASE REVIEW POLICY AND PROCEDURE - YOU MAY KEEP THIS FORM FOR FUTURE REFERENCE.-
For Ashley Wallen, FNP-C NEW Patients - ADDITIONAL PAPERWORK click to expand/collapse
Please have these additional forms completed prior to your first appointment. Forms are fillable - once completed in adobe, SAVE AS and rename document with patient name.
DR SHAH NAWAZ ADDITIONAL FORMS click to expand/collapse
PLEASE COMPLETE THESE ADDITIONAL FORMS AND RETURN WITH OTHER INTAKE PAPERWORK - REMEMBER TO SAVE AS - WITH YOUR NAME.
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NAWAZ SYMPTOM CHECK LIST PLEASE COMPLETE ATTACHED FILLABLE FORM. SAVE AS - WITH YOUR NAME AND SEND BACK WITH OTHER INTAKE PAPERWORK-
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OCI - R FORM PLEASE COMPLETE THE FILLABLE ATTACHED FORM AND SAVE AS WITH YOUR NAME AND RETURN WITH OTHER INTAKE PAPERWORK-
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NAWAZ MEDICATION HISTORY LIST PLEASE REVIEW MEDICATION LIST AND IDENTIFY IF YOU 1) HAVE EVER TAKEN THE MEDICATION 2) IF TAKEN, WAS IT HELPFUL4.1.2021
For Dr. Jason Chang NEW Patients - ADDITIONAL PAPERWORK click to expand/collapse
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
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Dr. Jason Chang Practice Guidelines and Policy and Procedures Please review and sign last page and bring to initial appointment.1.1.20
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Parent Questionaire and Behavioral Checklist - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! Please complete both forms prior to the patients first appointment.3.24.20
For Dr. Sandy Rhee NEW Patients - ADDITIONAL PAPERWORK click to expand/collapse
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
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Dr. Sandy Rhee Practice Guidelines and Policy and Procedures Please review Dr. Rhee's guidelines and sign last page. Bring to initial appointment.1.1.20
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Parent Questionaire and Behavioral Checklist - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! Please complete both forms prior to the patients first appointment.3.24.20
For Dr. Ella Komarovsky New Patients - ADDITIONAL PAPERWORK click to expand/collapse
Please print and complete the forms prior to the appointment if scheduled with Dr. Ella Komarovsky. Please also print any release of information or other forms that may apply. Bring to initial appointment. DO NOT PRINT DOUBLE SIDED
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Dr. Ella Komarovsky Guidelines and Policy and Procedures Please print forms out and review them prior to your visit with Dr. Komarovsky. Please bring forms with you and sign last page.1.1.20
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Parent Questionaire and Behavioral Checklist - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! Please complete both forms prior to the patients first appointment.3.24.20
For Dr. Donna Woods NEW Patients - ADDITIONAL PAPERWORK click to expand/collapse
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
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Dr. Donna Woods Guidelines and Policy and Procedures Please review and sign last page of packet. Bring to initial visit.1.1.20
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Parent Questionaire and Behavioral Checklist - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! Please complete both forms prior to the patients first appointment.3.24.20
For Dr. Barry Lipin Forms click to expand/collapse
Please also print any forms from the Additional Forms section, that apply.
For Dr. Brian Zercher’s Forms click to expand/collapse
Please also print any forms from the Additional Forms section, that apply.
Additional Forms click to expand/collapse
Print any that apply.
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Consents and Authorizations - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! 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.11/2020
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CLIENT INFORMATION FORM - FILLABLE AFTER COMPLETING THE FORM, SAVE AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! COMPLETE ALL SECTIONS. THANK YOU!09/21
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Credit Card Authorization Form - Fillable AFTER COMPLETING - USE SAVE AS FUNCTION AND SAVE IT WITH YOUR NAME, OTHERWISE IT WILL COME TO US BLANK!!! Form is fillable. Please make sure to list name of Cardholder on the form.01/2022
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POLICY AND PROCEDURES - MD'S PLEASE REVIEW DOCUMENT - THIS FORM IS YOURS TO KEEP-
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Patient Rights/Notice of Privacy Practices This is for you to keep - no need to bring it into your first appointment1.1.20
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Release of Information Form - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! If you would like PRA to communicate with outside agencies, schools, or PCP – you will need one for each separate contact.2020
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Exchange of Information Form - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! 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.3.24.20
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New Insurance Form - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! 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. This form is fillable.1.28.2022
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Address Change Form2020
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Request for copy of own personal Medical Records Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! Please complete and return to the office for your clinician to review12.1.21
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Within PRA Release of Information To be used when authorizing communication between therapists/MD’s WITHIN PRA.1/1/20
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Alert Wellness Assessment – Adult Fillable (For United Healthcare -UHC/Optum only) Please complete form - SAVE AS your First Name and Last Name and then drop box it to office staff that you spoke with4/2020
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Alert Wellness Assessment – Youth Fillable (For United Healthcare -UHC/Optum only) Please complete form - SAVE AS with your First and Last Name and then drop box it to office staff that you spoke with4/2020
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TELEHEALTH - CHECKING INTO YOUR SESSION GUIDE OF HOW TO SIGN IN FOR YOUR VIRTUAL VISIT3.18.20
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TELEHEALTH CONSENT FORM PLEASE SIGN AND RETURN PRIOR TO YOUR FIRST TELEHEALTH -FILLABLE FORM. SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!!11/2020
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DROP BOX - HOW USE DROPBOX - STEP BY STEP INSTRUCTIONS EXPLAINS HOW TO DROP BOX PAPERWORK TO PRA6.2020
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MEDICAL HISTORY FORM - FILLABLE SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! PLEASE COMPLETE ALL ASPECTS OF THIS FORM3/2020
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POLICY SIGNATURE PAGE - Fillable SAVE THE FORM AFTER COMPLETING IT AS YOUR FULL NAME, THEN SEND TO OUR OFFICE!!! OTHERWISE IT WILL COME TO US BLANK!!! PLEASE SIGN AND RETURN AFTER READING THROUGH ALL POLICIES-
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PHQ9 AND GAD7 ASSESSMENTS Please have these additional forms completed prior to your first appointment. Forms are fillable - once completed in adobe, SAVE AS and rename document with patient name.-
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Therapist Policy and Procedures Please print and review for contacting your therapist3.23.20
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Request to Revoke an Authorization Complete form in full to Request to Revoke an Authorization that is on file.01.2022