FORMSTap on any form below that corresponds to you: ADULT REGISTRATION FORM ADULT REGISTRATION FORM Patient’s Name * First Name Last Name Date of Birth (required) MM DD YYYY Home Phone (###) ### #### Cell Phone (###) ### #### Text OK? YES NO Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Work Phone (###) ### #### Spouse/Significant Other: Name First Name Last Name Date of Birth MM DD YYYY Home Phone (###) ### #### Cell Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Work Phone (###) ### #### Children/Age(s): EMERGENCY CONTACT: Name * First Name Last Name Phone * (###) ### #### Relationship * PRIMARY CARE PHYSICIAN Doctor's Name First Name Last Name Phone (###) ### #### Practice Name REFERRAL SOURCE: Name First Name Last Name Phone (###) ### #### Thank you for submitting the adult registration form! We can’t wait to meet with you! We will get in contact with you shortly! CHILD/ADOLESCENT REGISTRATION FORM CHILD/ADOLESCENT REGISTRATION FORM PATIENT INFORMATION Name * First Name Last Name Email * Date of Birth (required) MM DD YYYY Home Phone (###) ### #### Cell Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country PARENT INFORMATION MOTHER'S Name * First Name Last Name Date of Birth * MM DD YYYY Home Phone (###) ### #### Cell Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Work Phone (###) ### #### FATHER'S Name * First Name Last Name Date of Birth * MM DD YYYY Home Phone (###) ### #### Cell Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Work Phone (###) ### #### Marital Status: Marital Status * CHOOSE ONE: Married Separated Divorced Who has custody? * CHOOSE ONE: Mother Father Both Siblings/Ages (Type "N/A" if only child): * PRIMARY CARE PHYSICIAN Doctor's Name First Name Last Name Doctor's Phone (###) ### #### Practice Name: REFERRAL SOURCE: Name First Name Last Name Phone (###) ### #### Thank you for submitting the child registration form! We can’t wait to meet with you! We will get in contact with you shortly! RELEASE OF INFORMATION FORM * RELEASE OF INFORMATION FORM Patient Name * First Name Last Name Date of Birth (required) MM DD YYYY I, * First Name Last Name hereby authorize the mutual exchange of (Please print the name of patient or representative.) information between Aspen Leaf Holistic Mental Health and the following: (Name of hospital, physician, clinic, school, teacher, etc.) (Address of hospital, physician, clinic, school, teacher, etc., including city, state and zip code.) Address 1 Address 2 City State/Province Zip/Postal Code Country (Phone number) (Alternate phone number) (Fax Number) (###) ### #### I understand that information to be released for the purpose of psychiatric evaluation and ongoing treatment may include information regarding the following conditioning(s): - Psychiatric Conditions, Psychological Testing, Progress Notes, Medications Prescribed - Assessment including Diagnosis - Treatment Summary, Recommendations, Consultation - Drug and/or Alcohol Abuse - Medical Information - HIV (Human Immunodeficiency Virus)/AIDS (Acquired Immunodeficiency Syndrome) - Educational Information I understand that I may revoke this consent to release medical information at any time by giving written notice to Aspen Leaf Holistic Mental Health except to the extent that action has already been taken to comply with it. Without such revocation, this consent is valid until treatment with Aspen Leaf Holistic Mental Health ends. I release Aspen Leaf Holistic Mental Health from all legal responsibility and liability for the information released according to the terms of this written consent. I understand that there is the potential for this protected health information to be re-disclosed by the recipient and thus no longer protected under the HIPPA privacy rule. Signature of Patient: (if 15 years or older) First Name Last Name Date MM DD YYYY Signature of Parent or Legal Guardian: First Name Last Name Date MM DD YYYY Relationship to Patient : Thank you for submitting the Release of Information form! We can’t wait to meet with you! A team member will contact you in the next day or so! FREE ASSESSMENT SCREENINGClick the icons below to get a free screening for depression, bipolar disorder, and/or anxiety: DEPRESSION screening BIPOLAR DISORDER screening ANXIETY DISORDER screening
