Treatment Forms

Prior to your scheduled Diagnostic Intake Interview please print and complete the following forms. Completing these forms will expedite the intake process in order to facilitate the prompt commencement of treatment. The Mental Health Professional will review the completed documents will be reviewed with you at the time of the intake interview.

Consent to Release Billing Information   (pdf)
Consumer Informed Consent   (pdf)
Consumer Intake Form   (pdf)
Consumer Intake Questionnaire   (pdf)
Consumer’s Rights and Responsibilities   (pdf)
Consumer Non-Discrimination Notice (for client review only)   (pdf)
Ravenhill HIPPA Notice – Full Document (for client review only)   (pdf)
Ravenhill HIPPA Signature Page   (pdf)
Office Policies and Procedures – Full Document (for client review only)   (pdf)
Office Policies and Procedures – Highlights Signature Page   (pdf)
Parent Consent to Treatment – Required for children under the age of 14   (pdf)

*Consumers under the age of 14: In the event the child’s parents are separated/divorced and share custody BOTH parents must provide written consent before the child may participate in treatment

Please Note: Consumers are asked to bring the following with them to the Diagnostic Intake Interview:

• Completed Treatment Forms
• Insurance Card
• Driver’s License (or other photo identification) – Consumers under the age of 14: Parent/Guardian must present photo identification
• Copy of most recent Psychiatric/Psychological Evaluation (if applicable)
• Copy of IEP (if applicable)
• Copy of Child Custody Order/Decree (if applicable)