Forms

To save you some time please download, fill out, and bring these forms to your first appointment.

If you are unable to print these forms, you can contact us at 319-378-1199 and we can email you forms that you can email back. (no printing)
Click the appropriate group below:

Our Standard New Client Paperwork

Adult

Please fill out all 3 of these forms.

  1. Medical Social History Form
  2. Office Policy
  3. Demographic Sheet

        Veterans Only

  1. Medical Social History Form -Veterans only
Adolescent 12-18 yrs

Please fill out all 3 of these forms.

  1. Adolescent Social History form
  2. Office Policy
  3. Demographic Sheet
Child 11 yrs and under

Please fill out all 3 of these forms.

  1. Child Social History form
  2. Office Policy
  3. Demographic Sheet

 

Additional Forms When Requested

In Person Office Visit Guidelines

Required signature for anyone visiting in the office.

  1. In Person Office Visit Guidelines

Release of Information Form

If you would like to coordinate care with another provider (for example; your psychiatrist, primary care physician, your child’s school, etc.), print and complete our release of information form.

1. Authorization to Release Information form

Informed Consent of Teleservices

If for any reason you lose connection during your session time, your counselor will call you. You will not need to call the office.

  1. Informed Consent for Teleservices
Psychological Symptoms