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Forms for Your First Visit
Please download, print and fill out the following forms before your initial appointment with your clinician. Don't forget to bring everything with you to your visit! All forms are considered confidential and will not be released without your express permission (see the Notice of Privacy Practices form for more information on our confidentiality practices). If you have any questions, please call our office staff and they will be happy to assist you.
All forms require Adobe Acrobat Reader to open.
- Consent for Treatment
Our basic agreement between Renewal Center and the person receiving services. Please read carefully and initial or sign where indicated.
- Notice of Privacy Practices and Receipt
Read this document carefully and sign the last page. Keep the notice pages for your records.
- Financial Responsibility
This form indicates your method of payment for your services and indicates who will be responsible for payments.
- Fee Schedule
Our fees based on income if you are not using your insurance as part of your payment options.
- Brief Medical History
This form gives your clinician a basic overview of your medical history to help prepare a plan specifically for your needs.
- Authorization for Release of Information
Fill out this form if you need your information released to your physician, social worker, school or other associated person. Fill out one for each person/organization who requires this release.
- Psychosocial Information - Adult
Fill out this form if the person coming in for services is 18 years or older. This form gives your clinician a basic overview of your treatment goals, personal history and family history.
- Psychosocial Information - Child/Adolescent
Fill out this form if the person coming in for services is under 18. This form gives your clinician a basic overview of your treatment goals, personal history and family history.