• Patient Demographic Information Section

    The information in this section should be the for the Patient that is being seen.
  • (Pattison Professional Counseling and Mediation Center offers paperless patient statements via email. Additionally, you will receive a monthly newsletter providing you with interesting articles and informative information pertaining to health and wellness. You may opt-out of receiving the newsletter at any time.)

  • Clear
  • By entering my email address and signing, I hereby acknowledge that I will be receiving statements via email.

  • Emergency Contact Information

  • Brief Questionnaire

  •  / /Pick a Date
  • Responsible Party Information

    The information in this section should be the for the person financially responsible for the Patient.
  • Primary Insurance Policy Information

    If the information given is inaccurate, or the policy has termed, the patient or responsible party will be responsible for cost of visit.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Secondary Insurance Policy Information

    If the information given is inaccurate, or the policy has termed, the patient or responsible party will be responsible for cost of visit.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Authorization Information

  •  / /
    Pick a Date
  • Self Pay

  • Clinical Information

  •  
  • Medical History

    This medical information is used to detect possible medical problems that require a doctor's attention. Responses may result in the recommendation that you see your doctor for a physical examination.
  •  
  • Psychological Symptoms

  • Mental Health History

  •  
  • Family History

  • Please state which family members may have had any of the following:

  • Educational History

  • Goals for Treatment

  • Parent Coordination Information

  •  / /Pick a Date
  •  / /Pick a Date
  •  / /Pick a Date
  •  / /Pick a Date
  •  
  •  
  • Parent Coordination Agreement

  • Non-Disparaging Clause

  • Clear
  •  / /
    Pick a Date
  • Fees & Billing

  • General Terms & Conditions

  • Term, Rule Adjustments, & Court Order Supersedes Statements

  • I have read and understood the above Parenting Coordination Agreement and agree to abide by its terms:

  • Clear
  •  / /
    Pick a Date
  • Substance Abuse / Alcohol Screening

  • Drug History

  •  
  • Analysis of Current Problems

  • Clear
  •  / /
    Pick a Date
  • Domestic Violence Intervention Program

  • Domestic Violence Report

  •  
  •  
  •  
  •  
  •  
  •  
  •  
  • Medication Management

  • Clear
  •  / /
    Pick a Date
  • Clear
  •  / /
    Pick a Date
  • Psychological Evaluation

  • Notice of Privacy Policies & Communications

  • My signature acknowledges that I have read, understand, and agree to all parts of the Privacy Policies & Communications of Pattison Professional Counseling Center.

  • Clear
  •  / /
    Pick a Date
  • Financial Policy

  • My signature acknowledges that I have read, understand, and agree to all parts of the financial policy of Pattison Professional Counseling Center. I also understand that my account could be turned over to a collection agency if it becomes delinquent.

  • Clear
  •  / /
    Pick a Date
  • Client Rights

  • Client Responsibilities

  • I have read this list of rights and responsibilities or had them read to me. I understand and agree to them.

  • Clear
  •  / /
    Pick a Date
  • Informed Consent for Telehealth Services

  • I hereby attest by signature that I have read, understood, and agree to the terms of this document.

  • Clear
  •  / /
    Pick a Date
  • Notice of Protected Health Information & Communications

  • Clear
  •  / /
    Pick a Date
  • Should be Empty: