Forms For First Appointment

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Please print and then complete the following 5 forms and bring them to your first therapy session:

  1. Insurance Company Billing Authorization Form
  2. Patient  Information and Consent Form
  3. Primary Care Notification Form
  4. HIPAA Consent Form
  5. Adult History and Health Form or Child and Adolescent History and Health Form (under 18 years old)

If you would like us to talk to anyone about your therapy or treatment at Mielke and Weeks Psychological Services please print the following form and bring it with you and to discuss this with your therapist.

  1. Authorization Release Form

    Please refer to our HIPAA Consent tab for information regarding our commitment to protecting your Private Health Information. Thank You!

    Note: To download Adobe Acrobat Reader for free, click here .

Helpful Forms

Click here to view and print forms for your appointment.

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