Complete Form List

Registration Forms List by Packet

The forms below are offered in a fillable PDF format. You may fill them out online then print, or print first and fill out by hand.

New Client Packet:

If you have been seen for consultation/evaluation/treatment in the past and will be providing records, please complete the Release to Disclose Confidential Information Form, #6, and return directly to those providers.*

1. Consent for Healthcare Operations: PDF

2. Child Development Questionnaire: PDF

3. Consent to Treatment: PDF

4. Privacy Policy Acknowledgement and Consent Form: PDF

5. Release to Disclose Confidential Information*: PDF

6. Child Info Form: PDF

7. General Financial Policy – READ ONLY

8. Privacy Policy – READ ONLY

Speech/Language New Client Packet:

If you have been seen for consultation/evaluation/treatment in the past and will be providing records, please complete the Release to Disclose Confidential Information Form, #6, and return directly to those providers.*

1. Consent for Healthcare Operations: PDF

2. Child Development Questionnaire: PDF

3. Speech Development Questionnaire: PDF

4. Consent to Treatment: PDF

5. Privacy Policy Acknowledgement and Consent Form: PDF

6. Release to Disclose Confidential Information*:PDF

7. General Financial Policy – READ ONLY

8. Privacy Policy – READ ONLY

9. Speech Language Benefit Check Information – READ ONLY

Adult Packet:

If you have been seen for consultation/evaluation/treatment in the past and will be providing records, please complete the Release to Disclose Confidential Information Form, #5, and return directly to those providers.*

1. Adult Information Form: PDF

2. Consent for Healthcare Operations: PDF

3. Patient Health Questionnaire: PDF

4. Consent to Treatment: PDF

6. Privacy Policy Acknowledgement and Consent Form: PDF

7. Release to Disclose Confidential Information*:PDF

8. General Financial Policy РREAD ONLY

9. Privacy Policy РREAD ONLY

Returning Client Packet:

2. Consent for Healthcare Operations: PDF

3. Consent to Treatment: PDF

4. Privacy Policy Acknowledgement and Consent Form: PDF

5. Release to Disclose Confidential Information*:PDF

6. Child Info Form: PDF

7. General Financial Policy – READ ONLY

8. Privacy Policy – READ ONLY

Please send questions or comments to webmaster@childrensprogram.com