Mid Valley Counseling Center, Inc.
Psychiatric Mental Health Nurse Practitioners
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Clinical Psychologists
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Information
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Forms
Forms
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General Forms
Authorization for Release of Protected Health Information
Consent to use or disclose information for Treatment
Alternative Contact Information
Notice of Privacy Practices
Arvilla Claussen, RN PMHNP
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Client Questionnaire
Intake form
Intake Letter
William Davis, Psy.D.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Adult Information Form
Child / Adolescent Information Form
Intake Form
Intake Letter & Informed Consent
Randall Green, PhD.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Adult Information Form
Child / Adolescent Information Form
Contract for Therapy with a Minor
Informed Consent
Intake Form
Intake Letter
FAQ About Therapy for Teens
Amen Adult General Symptom Checklist
Keith Swanson, Psy.D. PC
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Contract for Therapy with Minor
Alternative Contact Information
Client Questionnaire
Child History Form
Intake Form
Intake Letter
Informed Consent
Nick Dietlein, Psy.D.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Adult Information Form
Child / Adolescent Information Form
Alternative Contact Information
Client Questionnaire
Intake Form
Intake Letter
Elizabeth Hamilton, PhD.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Adult Information Form
Child / Adolescent Information Form
Client Questionnaire
Intake Form
Intake Letter
Informed Consent
B. Scott Cook, Psy.D. PC
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Alternative Contact Information
Client Questionnaire
Intake Form
Intake Letter
Wayne Palmer, PhD.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Alternative Contact Information
Client Questionnaire
Intake Form
Intake Letter
Paul Stoltzfus, Psy.D.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Alternative Contact Information
Client Questionnaire
Intake Form
Intake Letter
Susan Hall, Psy.D.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Client Questionnaire
Intake Form
Intake Letter
Adam Fenske, Psy.D. PC
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Adult Information Form
Child / Adolescent Information Form
Informed Consent
Intake Form
FAQ About Therapy for Teens
Contract for Therapy with Minor
Amen Adult General Symptom Checklist
Carlos Taloyo, PhD.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Adult Information Form
Child / Adolescent Information Form
Intake Form
Informed Consent
Intake Letter
FAQ About Therapy for Teens
Contract for Therapy with Minor
Amen Adult General Symptom Checklist
Joel Gregor, PsyD.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Child History Questionnaire
Child History Form
Client Questionnaire
Intake Form
Intake Letter
Informed Consent
Contract for Therapy with a Minor
Amanda Arthurs, PsyD.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Adult Information Form
Adolescent Information Form
Amen Adult General Symptom Checklist
FAQ About Therapy for Teens
Informed Consent
Intake Form
Intake Letter
Contract for Therapy with a Minor
Winston Seegobin, PsyD.
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Client Questionaire
Contract for Therapy with a Minor
Intake Form
Intake Letter
Child History Questionnaire
Informed Consent
Michael Tremko, PMHNP-BC
Consent to use or disclose information for Treatment
Authorization for Release of Protected Health Information
Provider Policy on Insurance and Billing Practices
Alternative Contact Information
Notice of Privacy Practices
Child Adolescent Info Form
Adult Client Questionnaire
Intake Letter
Intake Form