For Legal Guardian to Complete
(i.e., Adoption Case Manager)

DOWNLOAD ENTIRE INTAKE PACKET

PDF Format

Individual Intake Forms

Referral Form

PDF Format

Documentation Checklist

PDF Format

Consent for Treatment

PDF Format

Rights & Responsibilities/Privacy Practices Acknowledgement (SEE REFERENCE BELOW)

PDF Format

Medicaid Payment Agreement/Authorization

PDF Format

After-Hours/Supervision Agreement

PDF Format

Authorization to Release/Obtain Information-ECA

PDF Format

Authorization to Release/Obtain Information-PCP

PDF Format

Authorization to Release/Obtain Information-Blank (ONLY USE AS NEEDED)

PDF Format

For Parent(s) to Complete

Intake Information

PDF Format

Symptom Checklist (ages 5 and up)

PDF Format

Symptom Checklist (ages 0-5)

PDF Format

Sensory Integration Disorder Screening

PDF Format

For Children to Complete

Sentence Completion Form

PDF Format