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 provider. Please choose the appropriate set for the provider 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.
If you are planning on using your insurance and have any concerns or questions, we recommend calling the front desk and providing your insurance information.
Dr. Ah-Tye — Forms (click to open)
- New Patient Data Form
- HRC Provider-Patient Services Agreement (reading required, optional to print)
- Privacy Notice (reading required, optional to print)
- HIPAA Privacy Notice Form
- HRC Consent Form
- COVID-19 Informed Consent Form for In-Person Services
- Appointment and Script Authorization
- Psychiatry Missed Appointment and Treatment Form
- Credit Card on File Agreement
- General Adult Questionnaire – or – Confidential Child Questionnaire (age 18 or under)
Dr. Dedesma — Forms (click to open)
- New Patient Data Form
- HRC Provider-Patient Services Agreement (reading required, optional to print)
- Privacy Notice (reading required, optional to print)
- HIPAA Privacy Notice Form
- HRC Consent Form
- COVID-19 Informed Consent Form for In-Person Services
- Appointment and Script Authorization
- Consent Form for Prior Authorizations
- Psychiatry Missed Appointment and Treatment Form
- Credit Card on File Agreement
- General Adult Questionnaire
- Patient Health Questionnaire
- Review of Systems
Dr. Kamdar — Forms (click to open)
- New Patient Data Form
- HRC Provider-Patient Services Agreement (reading required, optional to print)
- Privacy Notice (reading required, optional to print)
- HIPAA Privacy Notice Form
- HRC Consent Form
- COVID-19 Informed Consent Form for In-Person Services
- Psychiatry Missed Appointment Form
- Credit Card on File Agreement
- Adult Questionnaire for Dr. Kamdar
- Mood Disorder Questionnaire
Dr. Pearson — Forms (click to open)
- New Patient Data Form
- HRC Provider-Patient Services Agreement (reading required, optional to print)
- Privacy Notice (reading required, optional to print)
- HIPAA Privacy Notice Form
- HRC Consent Form
- COVID-19 Informed Consent Form for In-Person Services
- Appointment and Script Authorization
- Psychiatry Missed Appointment and Treatment Form
- Credit Card on File Agreement
- Dr. Pearson’s New Patient Questionnaire
Dr. Perilstein — Forms (click to open)
- New Patient Data Form
- HRC Provider-Patient Services Agreement (reading required, optional to print)
- Privacy Notice (reading required, optional to print)
- HIPAA Privacy Notice Form
- HRC Consent Form
- COVID-19 Informed Consent Form for In-Person Services
- Appointment and Script Authorization
- Consent Form for Prior Authorizations
- Psychiatry Missed Appointment and Treatment Form
- Credit Card on File Agreement
- General Adult Questionnaire
- Patient Health Questionnaire
Dr. Steketee — Forms (click to open)
- Consent Form for Neuropsychological Evaluation
- HRC Neuropsychology Questionnaire
- National Academy of Neuropsychology Patient Information Sheet
- New Patient Data Form
- COVID-19 Informed Consent Form for In-Person Services
- Payment Agreement Form
- HRC Provider-Patient Services Agreement (reading required, optional to print)
- Privacy Notice (reading required, optional to print)
- HIPAA Privacy Notice Form
- Credit Card on File Agreement
All Other Providers
- New Patient Data Form
- HRC Provider-Patient Services Agreement (reading required, optional to print)
- Privacy Notice (reading required, optional to print)
- HIPAA Privacy Notice Form
- HRC Consent Form
- COVID-19 Informed Consent Form for In-Person Services
- Missed Appointment Policy
- Credit Card on File Agreement
- General Adult Questionnaire – or – Confidential Child Questionnaire (age 18 or under)
For Couples
We request that each person individually complete a packet.
- New Patient Data Form
- HRC Provider-Patient Services Agreement (reading required, optional to print)
- Privacy Notice (reading required, optional to print)
- HIPAA Privacy Notice Form
- HRC Consent Form
- COVID-19 Informed Consent Form for In-Person Services
- Missed Appointment Policy
- Credit Card on File Agreement
- General Adult Questionnaire
- Relationship Adjustment Questionnaire
- Marital Status Inventory
For Career Coaching
- New Client Data Form
- HRC Provider-Patient Services Agreement (reading required, optional to print)
- Privacy Notice (reading required, optional to print)
- HIPAA Privacy Notice Form
- Insurance Agreement
- HRC Consent Form
- COVID-19 Informed Consent Form for In-Person Services
- Missed Appointment Policy
- Credit Card on File Agreement