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Patient Intake Forms
 
Please complete the following forms in black ink and bring them to your first appointment:
  • Registration Form: This form gathers all of your basic demographic and contact information. It also asks about any treatment history you have had, medications you are taking, insurance information, who referred you, and allows you to briefly identify what you are coming to PTS to work on.
  • Adult History & Symptom Checker: This form gives your therapist a thorough sense of your current functioning and symptoms that may be bringing you to therapy at this time. This will supplement the clinical interview that your therapist will guide you through during your first session.
  • Child History & Symptom Checker: This form provides initial information about your child including current functioning and symptoms that may be bringing him or her to therapy at this time. This information will supplement a clinical interview and observation. The parent or legal guardian should complete the questionnaire for children 13 years and younger. Adolescents, 14 years and older, are asked to complete the form independently. Parents are also invited to complete this questionnaire for children 14 years and older as additional information for the therapist, if desired.
  • Relationship Assessment Questionnaire: If you are pursuing couples therapy within Perspectives, both you and your partner should complete this questionnaire prior to the intake session with your therapist. To clarify, you will each fill out your own questionnaire and bring to your first session.
  • Notice of Privacy Practices (HIPAA): No signature is required on this form. Please read it over so you are aware of your privacy protections. You will be asked to initial the Disclosure Statement and Consent to Treatment form indicating that you have read it.
  • Credit Card Authorization: This form serves as an authorization to input your credit card information into our secure system and charge it when a balance on your account exists.

 

 
 
 
 
     
To schedule an appointment call (810) 494-7180
 
© Perspectives Therapy Services
Brighton office: 120 Flint Street | Brighton, MI 48116 | 810-494-7180
Lansing office: 1701 Lake Lansing Road | Lansing, MI 48912 | 517-993-5474
Highland office: 2628 South Milford Road | Highland, MI 48357 | 248-529-3049
Howell office: 3469 E Grand River | Howell, MI 48843 | 810-494-7180
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