Couple Therapy Session

Patient Forms

Please review and fill out these forms then click "submit". A prompt will let you know that the forms have been submitted properly. We look forward to seeing you!

It is important to "submit" the forms instead of printing them yourself. If you print them and bring them in, it may result in having to to re-do the forms.

Thank You!

 

Patient Info Form

PCP Release

General Release

Pharmacy Intake

Intake Questionnaire

Financial Agreement and Worker's Compensation/No Fault

Privacy Notice and Confidentiality Agreement

Consent for Treatment (Required ONLY if you are seeing a Medical Provider)

Intake Questionnaire (For New Patients of Kenna Burns ONLY)