Intake Forms

REFERRAL FORM
KCCSreferral.pdf
Adobe Acrobat document [30.5 KB]

PATIENT NOTIFICATION OF PRIVACY RIGHTS
The notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information.
PLEASE REVIEW IT CAREFULLY!
Privacy Health Information Rights-HIPPA.[...]
Adobe Acrobat document [500.0 KB]

PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT
PSYCHOTHERAPIST-PATIENT AGREEMENT- NEW.p[...]
Adobe Acrobat document [406.6 KB]

ATTESTATION AGREEMENT FORM
By signing the form, you are stating that you understand and agree to enter into the terms and conditions of the Patient Notification of Privacy Rights and the Psychotherapist-Patient Services Agreement.
KUADRA-attestation form.pdf
Adobe Acrobat document [193.8 KB]

INSURANCE AND BILLING FORM
KUADRA insurance and billing form.pdf
Adobe Acrobat document [22.2 KB]

INITIAL MENTAL HEALTH ASSESSMENT
INITIAL MENTAL HEALTH ASSESSMENT.pdf
Adobe Acrobat document [198.5 KB]

RECORDS RELEASE FORM
CONSENT FOR COUNSELING OF A MINOR-Kuadra[...]
Adobe Acrobat document [222.7 KB]

HISTORY OF PRESENTING PROBLEMS IN CHILDREN
HISTORY OF PRESENTING PROBLEMS IN CHILDR[...]
Adobe Acrobat document [219.5 KB]

INTAKE FINANCIAL INFORMATION FOR UNDER 18
INITIAL INTAKE FINANCIAL INFORMATION-Kua[...]
Adobe Acrobat document [237.4 KB]

MEDICAL HISTORY QUESTIONNAIRE FOR MINOR
MEDICAL HISTORY QUESTIONNAIRE-FOR MINOR.[...]
Adobe Acrobat document [374.5 KB]

ALTERNATIVE-HOLISTIC ENERGY THERAPIES AGREEMENT
ALTERNATIVE-HOLISTIC ENERGY THERAPY AGRE[...]
Adobe Acrobat document [360.1 KB]