Form

Psychological Testing Intake Form

New Client Information – Adam Borecky, MD, or Kelly Culmore, …

New Patient History Mid Towne – Adult

New Patient History Form – Child (Parent please complete)

Credit Card Authorization Form

New Client Information – Mid Towne

MICHIGAN NOTICE FORMNotice of Therapist’s/Psychiatrist’s Policies and Practices to Protect thePrivacy of Our Patient’s Health InformationTHIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATIONABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESSTO THIS INFORMATION. PLEASE READ IT CAREFULLY.I. Uses and Disclosures for Treatment, Payment, and Health Care […]

Psychological Testing Intake Form

New Client Information – Adam Borecky, MD, or Kelly Culmore, …

New Patient History Mid Towne – Adult

New Patient History Form – Child (Parent please complete)

Release of Information Form

Credit Card Authorization Form

Medication Visit Form

New Client Information – Mid Towne

Psychology Associates of Grand Rapids HIPAA Notice

New Patient Form Parchment – Child (Parent please complete)