Located in Moline, IL | 309-797-2900
Patient Forms
Patient Forms
Call to schedule your initial appointment
at 309 797-2900 extension 4,
then
complete your paperwork via the link provided below.
All paperwork should be completed 24-48 hours prior to your appointment and should include your photo ID and insurance card.
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
Child / Adolescent
Miscellaneous forms
If you use these forms they must be printed signed and returned via mail, fax or email. Our contact information is below
- Release of Information
- Neuropsych Late Cancel Fee Policy
- HIPAA Service Agreement
- Telehealth consent
- Personal Release of Information This form is only to be used when patients are requesting records for themselves and not for a 3rd party.
Additional intake paperwork for RETURNING patients who are seeing the SAME Provider as in the past
- Adult Re-Evaluation This link is to be used if you are a returning adult patient who is seeing the same provider as previous and have not been seen for 6-9 months. If it has been over 9 months since you have seen the provider please complete the New adult therapy paperwork.
- Child Re-Evaluation this link is to be used if the patient is a returning child/ adolescent who is seeing the same Provider as previous and has not been seen for 6-9 months. If it has been over 9 months please complete the New child/adolescent therapy paperwork.
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
309-797-2900
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If you would like to be contacted to schedule an appointment with a Provider please leave your first name and phone number and we will contact you on our next business day. If you are attempting to contact your Provider Please call the office at 309 797-2900If you are in crisis call 911 or go to the emergency room
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