Forms

Useful documents for you

It’s important to learn where we are located – here, you’ll find abbreviated instructions.

acp_symbolWe recommend that you download, print, and fill out forms before your appointment. Bring the forms with you to your first session.

We recommend that you adjust your printer settings for these PDF files. Choose ‘shrink to fit‘ or ‘fit to page‘.

acp adult intake [19+]

This form includes a consent to treatment, consent to file insurance claims for you, and asks for information about you and your household. The 5th page addresses trauma history, allowing you to let us know if that is part of your concerns. The 6th page provides you with a quick symptom list – so you can let us know how you’re feeling, and how it’s impacted you in recent weeks. Print this out, and bring the completed form to your first appointment. Thanks!


If your child is coming for help, there are two documents to print out. We ask for family and developmental information, along with documenting consent for treatment and insurance filing. Please bring both of these with you to your family member’s first session. Thank you!

Child Adolescent Intake 2018 [18 and younger]

CHILD DEVELOPMENTAL HISTORY


Medication management

Elizabeth Wolfe, APRN, Molly Petersen, APRN and Jackie Marymee, APRN – offer assessments for medications used to help with mood, anxiety, or depression. Use this form for your first appointment.

Need information about handling an urgent situation regarding your medications? Please read this handout.


Other forms

Release of Information – this is the form to use when a set of records is to be sent to [or from] Associated Counseling Professionals.

Coordination of Care – this form is designed to establish a collaborative relationship between your ACP therapist and other healthcare professionals you work with.


Smoking Cessation:

Explanation of Services: StopSmoking2014Terry
Plus, these two items, please:
Smoking Questionnaire & Smoking Cessation Client form 2014