Forms

New Clients

If you are a new client, please fill out the forms below and bring them to your initial visit. You are welcome to pick up these forms at the Specialty Services Clinic front desk any time if you prefer. Please also remember to bring your health insurance information to your first visit.

  1. New Client Information
  2. Informed Consent
  3. Financial Agreement and Authorization for Treatment
  4. Privacy Policy
  5. Outcome Questionnaire for Adults (age 18 and above)
  6. Youth Outcome Questionnaire (age 17 and below)

Releasing Information

You will need to fill out and sign an Authorization for Release of Information if you would like me to share information with agencies or individuals about you or your child.

  1. Authorization for Release of Information for Adult
  2. Authorization for Release of Information for Child

  • Antje Rath
  • Clinical Mental Health Counselor
  • Phone: 435-719-5550
  • Fax: 435-719-5551