How to Fill Out and Submit Forms

*Please download Adobe Acrobat Reader prior to downloading the forms and then save them after they’re filled in. Thank you!

Consent Form for Telehealth

This 2-page PDF document is required for compliance with current laws that protect privacy and confidentiality which also apply to Telemental health services. Exceptions to confidentiality are described in the Notice of Privacy Practices that FPS uses. Telemental health services are provided through a HIPAA compliant and secure platform. No permanent video or voice recordings are kept from Telemental health sessions. Client may not record or store video from sessions.

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Consent Form for Telehealth  

Privacy Practices & HIPAA Form

This 6-page PDF document (including one-page form) is a required "notice of privacy practices" (NPP) in keeping with Federal HIPAA (Health Insurance Portability and Accountability Act, 1996) requirements. Click to download.

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Privacy Practices & HIPAA Form 

Initial Patient Information Form

Two-page form in PDF format: Name, address, phone, Emergency Contact Information, Receipt of Notice of Privacy Practices. Click to download.

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Initial Patient Information Form 

Medical Billing Information Form

One-page PDF form: Primary Care Provider, emergency contact info, insurance information.

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Medical Billing Information Form

Medication Information

Information on specific medications, side effects, and contraindications.  Also a link to a patient assistance program offering aid for people that need financial help paying for their medications.
1   Link  Medline Plus
2   Link  Patient Assistance Program
3   Link  The Healthy Place

ADHD

An assortment of traditional and alternative treatment approaches.
1  Link  ADHD Treatment Summary

12 Step Programs

Links to the most popular 12 step organizations with meeting schedules.
1   Link   Alanon/Alateen
2   Link   Alcoholics Anonymous
3   Link   Codependents Anonymous
4   Link   Gamblers Anonymous
5   Link   Narcotics Anonymous
6   Link   Overeaters Anonymous

Recommended Chiropractors

Here is a list of local chiropractors that are recommended by this office.
1   Link  Coastal Chiropractic
2 Link    New Haven Chiropractic &Therapy
3 Link    Pace Chiropractic