Forms
Please download, complete, and bring the following forms to your first appointment. If you have questions, call us at (267) 347-8208.
General Consent to Treat
Authorizes Springhouse Psychiatry providers to deliver medical care, testing, treatment, and prescribing of medications for current and future visits, including telehealth appointments.
Informed Consent for Assessment and Treatment
Outlines the assessment and treatment process, including your rights to ask questions, request outside consultations, and understand the scope of psychiatric services provided.
Notice of Privacy Practices Acknowledgement
Confirms receipt of our Notice of Privacy Practices, which explains how your protected health information may be used and disclosed for treatment, payment, and healthcare operations.
Patient Consent for AI Scribe Dictation
Provides consent for the use of AI scribe technology during appointments to transcribe spoken information into your medical records, along with details on privacy and security measures.
Patient Ethnicity Form
Collects race and ethnicity information as required by the government's electronic medical records program. You may also choose not to report this information.
Patient Financial Policy
Details our payment policies, including copayment expectations, insurance billing procedures, self pay rates, cancellation fees, and accepted forms of payment.
Telehealth Consent Form
Authorizes the use of telehealth and telemedicine services, explaining how electronic communications are used for diagnosis, therapy, and follow up care.
ADHD Evaluation Parent Questionnaire
A comprehensive questionnaire for parents to complete prior to a child's ADHD evaluation, covering medical history, developmental milestones, behavioral observations, education history, and family background.
General Anxiety Disorder Questionnaire (GAD 7)
A brief screening tool that measures the frequency and severity of anxiety symptoms over the past two weeks, used to help guide treatment decisions.
Patient Health Questionnaire (PHQ 9)
A nine item screening tool that assesses the frequency of depression symptoms over the past two weeks, used to support diagnosis and monitor treatment progress.
Understanding ADHD: Information for Parents
An educational resource from the American Academy of Pediatrics that explains ADHD symptoms, diagnosis, treatment options including medication and behavior therapy, and tips for supporting your child.
Authorization for Release of Medical Information
Authorizes Springhouse Psychiatry to request and receive health records from another provider or facility, including treatment records for physical health, mental health, and substance use.