New Client Forms

The following forms are provided for Meier Clinics clients who would like to print and complete them prior to their appointment. Please note: you may still need to sign or complete additional forms at the time of your appointment.

Please print all national forms and then check if any are listed under the state and program for which you are receiving care.

If you have any questions about the forms or need assistance in completing these forms, contact the office where you made your appointment. We will also be happy to answer any questions when you come in for your appointment or give us a call at 888-725-4642

All forms are provided in Adobe Acrobat. If needed, you may download this program for free at: get.adobe.com.

National Forms

• Notice of Privacy Practices and Client Rights For your information only
• Patient Registration Please complete all applicable sections
• Release of Information Carefully and fully complete this form if you want information about your care provided to another person.  Please note that there may be a charge for the copying and processing of medical records.  Your records are confidential and will not be provided to anyone without your written consent, except as allowed by federal and/or state law.

EN ESPANOL

• Registración Para Pacientes
• Aviso de Practicas de Privacidad y Derechos del Cliente
• Autorizacion Para Uso y Revelacion de Informacion de Salud Protegida (Illinois)
• Evaluación Psico-Social (Illinois)
  
• Autorizacion Para Uso y Revelacion de Informacion de Salud Protegida (Texas)

ILLINOIS

Outpatient

• Notice of Privacy Practices and Client Rights
• Patient Registration
• Psychosocial Assessment – Age 16 and Above (do not complete if only seeing a psychiatrist)
• The following form is for clients 15 years and younger:
  • Parent/Legal Guardian Questionnaire/Psychosocial (to be completed by parent/guardian for clients 15 years and younger – do not complete if only seeing a psychiatrist/M.D.)
• Consent for Telemedicine Services

Catalyst and Breakaway Forms

• Catalyst Schedule
• Morning IOP Schedule
• Breakaway Schedule
• Evening Catalyst Schedule

Neuropsychological Testing

• Children’s History Form
• Adult History Form

MARYLAND

• Notice of Privacy Practices and Client Rights
• Patient Registration
• Parent/Legal Guardian Questionnaire/Psychosocial (to be completed by parent/guardian for clients 15 years and younger)
• Psychosocial Assessment – Age 16 and Above 

PENNSYLVANIA

• Notice of Privacy Practices and Client Rights
• Patient Registration
• Parent/Legal Guardian Questionnaire/Psychosocial (to be completed by parent/guardian for clients 15 years and younger)
  
• Psychosocial Assessment – Age 16 and Above

TEXAS

Outpatient

• Notice of Privacy Practices and Client Rights
• Patient Registration
• Counselors & Psychologists – Ages 18 and up
• Counselors and Psychologists – Ages 12-17
• Counselors and Psychologists – Under Age 12
• Grant Davis – Ages 13-15
• Grant Davis – Ages 16 and up
• Rinda Jordan – Ages 13-15
• Rinda Jordan – Ages 16 and up
• Dr. Meier
• Dr. Trulson
• Dr. Vu

Catalyst and Freedom Forms

• Patient Forms (complete all applicable sections)

Medication Management

• Frequently Asked Questions

WASHINGTON

• Notice of Privacy Practices and Client Rights
• PatientRegistration
• Psychosocial Assessment – Age 16 and Above

The following form is only for clients 15 years old or younger.

• Parent/Legal Guardian Questionnaire/Psychosocial (to be completed by parent or guardian)