Forms

Below are listed some forms that you may find useful. Let us know if you cannot open one of the forms. Thank you.

  • Intake Form: his forms collects all relevant information regarding contact information, insurance information, family history, marital history and other personal information.
  • Intake Presenting Issue: This form collects information about the reason you are seeking therapy and the impact it has upon your life.
  • Medicaid Client’s Rights: This form should be signed by Medicaid patients only. It informs Medicaid patients of their rights as well as providing information on Advanced Directives and Well-Child Exams (EPSDT).
  • Permission for Minors: This form must be signed by the parents/caretakers of the child (17 & Younger) before they can receive care from A Window of Hope Counseling Center and its staff. If you are divorced and have joint custody, both parents must sign the form. If you have sole custody of your child/children, you must produce the court document stating that you have sole custody of your child at the time of the first meeting (intake). Include the name of each child you wish to be seen.
  • Release of Information: If you want A Window of Hope to share information with anyone not listed on the “Informed Consent,” you must sign a release of information form, which stipulates who the information is to be sent to or received from and the reason for doing so. A separate form must be filled out for each person/institution for which information is to be shared.
  • Child Symptom Inventory: This form is intended to identify possible mental health issues for children. It should be filled by the parent/caretaker of the child. Depending upon the child’s age, the parent/caretaker should consult the child to help them fill out the first 55 questions, the remainder to be filled out they parent/caretaker only. One form should be filled out for each child attending the session.
  • Adult Symptom Inventory: This form is designed to indicate possible DSM-5 (Diagnostic and Statistical Manual of the American Psychiatric Association) issues to facilitate an accurate diagnosis of your condition. Please fill it out as accurately and truthfully as possible. It is used for persons 18-years of age and older and one form should be filled for each adult attending the session.
  • Adult ADHD Symptom Checklist: This is an 18-item self-report inventory used to screen for ADHD in adults.
  • Vanderbilt ADHD Assessment – Parent’s Form: This form is designed for parents/caretakers to assess their child’s behaviors at home.
  • Vanderbilt ADHD Assessment – Teacher’s Form: This form is designed for teachers to assess the child’s behaviors at school.

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