NEW CLIENT FORMS BY LOCATION

 

The following forms are provided for Meier Clinics clients who would like to print and complete them prior to their appointment.  Please note:  you may still need to sign or complete additional forms at the time of your appointment.

 

Please print forms listed under the state and program for which you are receiving care.  If you have any questions about the forms you should use or need assistance in completing these forms, contact the office where you made your appointment.  A list of clinics, including phone numbers and addresses, can be accessed on our Locations page.  We will also be happy to answer any questions when you come in for your appointment.

 

NOTE:  All forms are provided in Adobe Acrobat.  If needed, you may download this program for free at http://get.adobe.com/reader/otherversions/.

 

CALIFORNIA

• Notice of Privacy Practices and Client Rights (for your information only)
• Patient Registration (complete all applicable sections)

 

ILLINOIS

Outpatient

Day Programs (Adult and Adolescent "Breakaway")

Consent for Follow-up Contact / Referral - Outpatient (optional, but appreciated) Notice of Privacy Practices and Client Rights (for your information only) Patient Registration (complete all applicable sections) Psychosocial Assessment - Age 16 and Above (do not complete if only seeing a psychiatrist/M.D.) The following form is for clients 15 years and younger. Parent/Legal Guardian Questionnaire/Psychosocial (to be completed by parent/guardian for clients 15 years and younger - do not complete if only seeing a psychiatrist/M.D.)

Notice of Privacy Practices and Client Rights (for your information only) Patient Registration (complete all applicable sections)

 

KANSAS

• Notice of Privacy Practices and Client Rights (for your information only)
• Patient Registration (complete all applicable sections)

 

MARYLAND

• Notice of Privacy Practices and Client Rights (for your information only)
• Parent/Legal Guardian Questionnaire/Psychosocial (to be completed by parent/guardian for clients 15 years and younger)
• Patient Registration (complete all applicable sections)
• Psychosocial Assessment - Age 16 and Above 

 

PENNSYLVANIA

• Notice of Privacy Practices and Client Rights (for your information only)
• Parent/Legal Guardian Questionnaire/Psychosocial (to be completed by parent/guardian for clients 15 years and younger)
• Patient Registration (complete all applicable sections)
• Psychosocial Assessment - Age 16 and Above

 

TEXAS

Outpatient	Day Programs (Adult, Sexual Addictions)
Please complete the forms provided according to who you are seeing.   Counselors and Psychologist only   Dr. Meier   Dr. Torres-Roca   Dr. Trulson	Please complete all of the attached forms.

 

 

VIRGINIA

Outpatient	Day Program
Notice of Privacy Practices and Client Rights (for your information only) Patient Registration (complete all applicable sections) Psychosocial Assessment - Age 16 and Above	Notice of Privacy Practices and Client Rights (for your information only) Patient Registration (complete all applicable sections) Psychosocial Assessment - Age 16 and Above

 

 

WASHINGTON

Outpatient	Day Program
Notice of Privacy Practices and Client Rights (for your information only) Patient Registration (complete all applicable sections) Psychosocial Assessment - Age 16 and Above   The following form is only for clients 15 years old or younger. Parent/Legal Guardian Questionnaire/Psychosocial (to be completed by parent or guardian)	Notice of Privacy Practices and Client Rights (for your information only) Patient Registration (complete all applicable sections)

 

NOTE:  All forms are provided in Adobe Acrobat.  If needed, you may download this program for free at http://get.adobe.com/reader/otherversions/.

NATIONAL FORMS

 

The following forms are for use at all Meier Clinics locations.  If you have any questions, please contact us at

888-725-4642.

 

 

Authorization for Use and Disclosure of Protected Health Information.  Carefully and fully complete this form if you want information about your care provided to another person.  Please note that there may be a charge for the copying and processing of medical records.  Your records are confidential and will not be provided to anyone without your written consent, except as allowed by federal and/or state law. 

 

IMPORTANT NOTES: 

• Illinois law requires that clients 12 years old and up sign the form; the parent's signature is not accepted in lieu of the adolescent's. 
• Texas law requires that clients 16 years and up sign the form; the parent's signature is not accepted in lieu of the adolescent's. 

 

Financial Disclosure.  If you do not have insurance coverage and have been informed that you qualify for discounted care, you must complete this form and provide the required documentation.  Discounts are subject to review and may be changed or discontinued if your financial situation changes or if you obtain health insurance coverage. 

 

 

NOTE:  All forms are provided in Adobe Acrobat.  If needed, you may download this program for free at http://get.adobe.com/reader/otherversions/.

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