Intake & Administrative Forms

Please see the links below to the documents required for your appointment.

Psychiatric Evaluation for Medication Management

Evaluation Intake + Policies & Procedures Form

Completion time: Approx. 20 minutes

Release of Information - General - Therapist

Completion time: Approx. 10 minutes

Release of Information - General - Healthcare Provider

Completion time: Approx. 10 minutes

Insurance Info Form for Prior Authorizations

Completion time: Approx. 3 minutes

Medical Marijuana Certification Evaluation

Medical Marijuana Intake + Policies & Procedures Form

Completion time: Approx. 25 minutes

Medical Marijuana Acknowledgement & Disclosure Form

Completion time: Approx. 5 minutes

Release of Information - Medical Marijuana - Therapist

Completion time: Approx. 10 minutes

Cheyney University Students

Cheyney Students Evaluation Intake + Policies & Procedures Form

Completion time: Approx. 20 minutes

Release of Information - General - Therapist

Completion time: Approx. 10 minutes

Release of Information - General - Healthcare Provider

Completion time: Approx. 10 minutes

Insurance Info Form for Prior Authorizations

Completion time: Approx. 3 minutes

Forms for Existing Patients

Insurance Info Form for Prior Authorizations

Completion time: Approx. 5 minutes

Release of Information - General - Therapist

Completion time: Approx. 10 minutes

Release of Information - General - Healthcare Provider

Completion time: Approx. 10 minutes