Patient Forms

New Patient Packet

New patients should plan to download, review, and complete the following packet prior to their first visit:

Click on the above image to download the packet

Individual Patient Forms

Patient registration form

Care provider form

ROI form

General operational policies and procedures form

Receipt of privacy practices form

Financial policy form

Notice of privacy practices form

Credit card policy form

Vanderbilt Assessment Forms

Vanderbilt
Parent Initial Assessment

Vanderbilt
Parent follow-up

Vanderbilt
Teacher Initial Assessment

Vanderbilt
Teacher follow-up

Screen for Child Anxiety Related Disorders

To be filled out by Child

To be filled out by Parent

Insurance Billing
We are not in network with any insurance companies, and payment is due in full at the time of service. We provide a Superbill (a detailed receipt) that can be submitted to insurance for reimbursement, and are happy to provide assistance with that process if needed. Here are some links to reimbursement forms/procedures for some of the more common insurance plans:

Aetna: Health Reimbursement Claim Form

Cigna: Reimbursement Medical Claim Form

Providence: Member Forms

Regence: Direct Member Reimbursement Form

United: Medical Claim Form

MODA: Claim Forms