Mt. Hood Banner

Forms

Please download and complete all forms and bring them to our first appointment

For clients 18 and younger or still in high school

  1. Client Information Form
  2. Child History Form (18 and younger)
  3. HIPAA Statement
  4. Disclosure for Treatment
  5. Informed-Consent-Checklist-for-Telepsychology-Services
  6. Authorization for Release/Exchange of Information

For clients 19 and older

  1. Client Information Form
  2. Adult Personal History Form (19 and older)
  3. HIPAA Statement
  4. Disclosure for Treatment
  5. Informed-Consent-Checklist-for-Telepsychology-Services
  6. Authorization for Release/Exchange of Information
Skip to content