Compassion, Understanding, Healing
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Forms
Forms
1. Client Intake Form
New Client Intake Form 2022 .pdf
(PDF — 113 KB)
New Client Intake Form 2022 .pdf
(PDF — 113 KB)
2. Informed Consent Form
Informed Consent Form 2022.pdf
(PDF — 108 KB)
Informed Consent Form 2022.pdf
(PDF — 108 KB)
3. HIPPA / Consent to Release Information Form
4. Adult Functional Assessment Tool
Functional Assessment Tool 2017.pdf
(PDF — 442 KB)
Functional Assessment Tool 2017.pdf
(PDF — 442 KB)
5. Consent to Treat a Minor
Consent to Treat a Minor Form 2022.pdf
(PDF — 496 KB)
Consent to Treat a Minor Form 2022.pdf
(PDF — 496 KB)
6. Child History Form
(PDF — 76 KB)
(PDF — 76 KB)
7. Child Characteristics Checklist
Child Checklist of Characteristics.pdf
(PDF — 205 KB)
Child Checklist of Characteristics.pdf
(PDF — 205 KB)
8. Fees and Policies
Bernstein Fees and Policies Form 2022.pdf
(PDF — 11 KB)
Bernstein Fees and Policies Form 2022.pdf
(PDF — 11 KB)
9. Credit Card Pre-Authorization
Credit Card Pre-Authorization Form 2022.pdf
(PDF — 361 KB)
Credit Card Pre-Authorization Form 2022.pdf
(PDF — 361 KB)