Patient Forms

Patient Forms

All paperwork is to be completed 48 hours prior to your scheduled appointment

Your information will be sent directly to the office of Southpark Psychology and the Provider will be given your paperwork at the time of your appointment.

Please note all of our Providers are in private practice. They do not share any paperwork.

If you are seeing a different or "New" Provider all paperwork must be completed for that Provider

Adult Therapy- complete if you are seeing a therapist

New Adult Therapy Paperwork

If you are a returning adult patient who is seeing the same provider as previous and have not been seen for 6-9 months please complete the below paperwork. If you are over 9 months please complete the New adult therapy paperwork

Adult Re-Evaluation

Child / Adolescent

New Child/ Adolescent Paperwork

If you are a returning child/ adolescent patient who is seeing the same provider as previous and have not been seen for 6-9 months please complete the below paperwork. If you are over 9 months please complete the New adult therapy paperwork

Child Re-Evaluation

Nurse Practitioner/Medication Management

Kate Stamer ARNP and Christina Nordick APRN require different forms

Nurse Practitioners- Medical information

Your New patient paperwork will be sent via email to the email you gave us at time of scheduling

All forms must be completed 48 hours prior to your appointment

Nurse Practitioners- Billing information

For all Medication management appointments you must complete the one page billing form and upload your photo Id and insurance cards.

Adult Initial Consultation Form

For any patient under the age of 18 the below form is to be used instead of the adult initial intake form

Child Initial Consultation Form

PLEASE ARRIVE AT LEAST 15 MINUTES BEFORE YOUR APPOINTMENT

Miscellaneous forms

If you use these forms they must be printed signed and returned via mail, fax or email. Our contact information is below

Disclaimer: Information contained in this site or linked sites is intended to be educational in nature and a tool for further exploration. It is not meant to be a substitute for psychological, legal or other professional advice.

309-797-2900