Patient forms
Patient Forms
Completing your paperwork before you arrive means your first appointment is spent talking rather than writing. This packet covers psychiatry, medication management and individual therapy visits.
The forms in this packet
You can print these and complete them before your visit, or arrive 15 minutes early and fill them in here.
Patient Consent for Treatment
Your written consent to begin care with our clinicians.
Patient Consent for TreatmentPDF · 384 KBNew Patient Form
Contact details, insurance information and basic history.
New Patient FormPDF · 380 KBPatient Health Questionnaire
A short symptom and history questionnaire your clinician reviews before the visit.
Patient Health QuestionnairePDF · 356 KBMedical Records Release
Authorises us to request or send records to another provider.
Medical Records ReleasePDF · 58 KBPsychotherapy Notes Release
A separate authorisation, required specifically for therapy notes.
Psychotherapy Notes ReleasePDF · 65 KBTelehealth Services Policy
How video visits work, and what you agree to when using them.
Telehealth Services PolicyPDF · 56 KB
Starting TMS or Living Free 365 instead? TMS Patient Forms or Living Free 365 Patient Forms.
What is in the packet
- Patient information and demographics
- Medical and psychiatric history, including medications you have tried
- Consent for treatment
- Notice of Privacy Practices acknowledgement (HIPAA)
- Financial responsibility and insurance assignment
- Release of information, if you want us to coordinate with another provider
How to get your copy
Call (502) 454-8800 and we will email or mail the packet to you, or arrive fifteen minutes early and complete it in the waiting room. Bring photo ID, your insurance card, and a list of your current medications and doses.
Please do not email medical details
Standard email is not a secure channel. Return completed forms in person or by the method our staff give you. Nothing on this website asks for medical information.
What happens next
- 1Print and complete every page — incomplete history is the most common cause of a delayed first visit.
- 2Bring it with you to 3430 Newburg Road, Suite 210, or call (502) 454-8800 if you need a copy mailed.
- 3Arrive 15 minutes early with ID, insurance card and medication list.
Prefer to talk? Call (502) 454-8800. We respond within one business day.
Request an appointment
Tell us how to reach you and what you're looking for. We'll confirm your insurance, answer your questions, and find a time that works. No long intake before you hear from a person.
- We respond within one business day.
- Most insurance accepted, including TRICARE and Medicare.
- In-office visits on Newburg Road, plus telehealth.
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