Welcome to the portal for Psychology Associates of Grand Rapids forms.

The forms provided here are for the use of Psychology Associates of Grand Rapids patient and staff only. Your privacy is our number one concern and any information provided by you through this site is protected by industry-standard encryption and subject to our privacy policy. By filling out forms on our site you agree to the statements in our privacy policy. You can view our privacy policy by clicking here.

*PLEASE COMPLETE THESE FORMS NO LESS THAN 48 HOURS IN ADVANCE OF YOUR APPOINTMENT*

If you have a teletherapy appointment, the forms below are *REQUIRED*:

• Informed Consent for Telepsychology
• Client Authorization for Disclosure of Protected Health Information Via Electronic Communication
• If you are a new patient please also fill out:
  • New Client Information – Parchment
  • New Patient Info (Adult) OR
  • New Patient Info (Child – Parent, please complete)

If your appointment is at our Parchment Office the forms below are *REQUIRED*:

• New Client Information – Parchment
• New Patient History Form Parchment – Adult OR
• New Patient History Form Parchment – Child (Parent please complete)
• HIPAA Privacy Policy (For your review)

If your appointment is at our Mid Towne Office, the forms below are *REQUIRED*:

• New Client Information – Mid Towne
• New Patient History Form Mid Towne – Adult OR
• New Patient History Form Mid Towne – Child (Parent please complete)
• HIPAA Privacy Policy (For your review)

If you are scheduled to see Kelly Culmore, DNP, please fill out the form listed below:

• New Client Form – Nurse Practitioner

Authorization Forms

• Credit Card Authorization Form
• Release of Information Form