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

  5/2012
•  Consents and Authorizations

  9/2014
•  Credit Card Authorization Form Helpful to have set up with teens or other patients for copays.

  2014
•  Patient Rights/Notice of Privacy Practices
•  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.

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

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

•  Client Information Form

  5/2012
•  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

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

•   Preparation for Biofeedback Assessment
•  Checklist of Changes

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
•  Drop Box