Forms for First Visit
Please read the following document. No need to print.
-HIPPA Policy
-HIPPA Policy
Provider Specific Forms
Leif Benjestorf and Erika Giraldo
-Release of Information
Please print and fill out forms below. Bring them to your first visit:
-Complete Intake Packet (All Forms In One Easy to Print File)
Individual Forms:
-Registration Form
-HIPPA Policy Signature Form
-Treatment Consent Form
-Mood Questionnaire
-Patient Health Questionnaire
-Adult ADHD Self Report Scale
-Consent for Electronic Communication (Email/Text)
Telemedicine Forms:
-Telemedicine Consent Form
Please print and fill out forms below. Bring them to your first visit:
-Complete Intake Packet (All Forms In One Easy to Print File)
Individual Forms:
-Registration Form
-HIPPA Policy Signature Form
-Treatment Consent Form
-Mood Questionnaire
-Patient Health Questionnaire
-Adult ADHD Self Report Scale
-Consent for Electronic Communication (Email/Text)
Telemedicine Forms:
-Telemedicine Consent Form
Photo taken at Yellowstone National Park 2016