HRC Forms

If you have an appointment to see one of our service providers, you will be asked to complete a number of forms. To save time, you may want to download and complete these forms prior to coming in. Listed below are the forms required for each doctor. Please choose the appropriate set for the Doctor you plan to see.

You will need the free Adobe Reader to view or print any of the Acrobat files linked to from this page.

Dr. Kamdar

• New Patient Data Form
• HRC Authorization Form
• HRC Provider-Patient Services Agreement
• Privacy Notice
• Missed Appointment Agreement
• Adult Questionnaire for Dr. Kamdar
• Mood Disorder Questionnaire

Dr. Perilstein

• New Patient Data Form
• HRC Authorization Form
• HRC Provider-Patient Services Agreement
• Privacy Notice
• Insurance Notice
• General Adult Questionnaire
• Patient Health Questionnaire

Dr. Prakken

• New Patient Data Form
• HRC Authorization Form
• HRC Provider-Patient Services Agreement
• Privacy Notice
• Pain Assessment

Dr. Steketee

• HRC Neuropsychology Background Information
• National Academy of Neuropsychology Patient Information Sheet
• New Patient Data Form
• HRC Authorization Form
• Payment Agreement Form
• HRC Provider-Patient Services Agreement
• Privacy Notice

All Other Providers

• New Patient Data Form
• HRC Authorization Form
• HRC Provider-Patient Services Agreement
• Privacy Notice
• General Adult Questionnaire or Confidential Child Questionnaire (age 18 or under)

For Couples

• Relationship Adjustment Questionnaire
• Marital Status Inventory