If you're a first-time client, please review and complete the following forms. Please scan back by email or fax 24 hours prior to your scheduled intake. Fax 888.910.0622.
- Client Intake Form
- Limits of Confidentiality
- Credit Card Authorization Form (required to be faxed in advance of initial appointment for all clients, incl. cash paying clients)
- Cancellation Policy Form (required by fax in advance of initial appointment.
Other forms:
- Consent to Release Information Form (if required) Use this form is you wish to authorize a release of information or coordinate information with another medical or legal entity, such as a medical doctor, medical laboratory, psychiatrist, endocrinologist, or attorney. This release is specific to persons, agencies, medical entities, and to obtain test results (of any kind) and attorneys. Please fill one out for each entity you wish to release information to or from.
SYMPTOMS
- Becks Depression Inventory
- Becks Anxiety Inventory
- Pyroluria Questionnaire
- ADULT Neurotransmitter and Health Assessment Questionnaire (NTAF - to be filled out by clients with mood concern
- CHILD Neurotransmitter and Nutrition Assessment Questionnaire (to be filled out by parents)
- M2/NEUROGISTICSE-Health Profile
- Symptom Assessment (initial and follow up assessment form)
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