OFFICE FORMS

Please read ALL the instructions before completing the required fillable forms. These forms are “fillable” but you will still need to print them to return them to us. The data will not save.

***If you are unable to print and complete the required forms prior to your appointment, you must complete them at our office.  You will need to come in early, 10-15 minutes per form.  If you do not come in early enough to complete the forms prior to your scheduled appointment time, we will need to reschedule your appointment, as the full 50 minutes of appointment time is needed to complete your intake.

PATIENT REGISTRATION FORM  You must read the Treasure Valley Psychology LLC Service Agreement document below prior to completing this form.

TREASURE VALLEY SERVICE AGREEMENT

NOTICE OF PRIVACY PRACTICES BOOKLET ENGLISH

NOTICE OF PRIVACY PRACTICES BOOKLET SPANISH

AUTHORIZATION TO RELEASE INFORMATION FORM  Idaho Statute 16-2428(1) requires children 14   years and older complete and sign this form allowing/authorizing the provider to speak with the parent(s)/guardian(s) or other individuals, about patient care. Adult patients or parents of children under 14 years old must sign this form before we can obtain/release information with any other individual.  Click here for instructions on how to complete this form.

PARENTAL CONSENT FORM Required for any minor to receive treatment.

HEALTH HISTORY FORM Required for patients of Michelle Cullinan

HEALTH STATUS FORM Required for patients of Michelle Cullinan

PSYCHIATRIC MEDICATION USE HISTORY Required for patients of Michelle Cullinan