Registration Forms List by Packet
The forms below are offered in a fillable PDF format. Please download the form first, complete and email it to paperwork@childrensprogram.com
New Client Packet:
If you have been seen for consultation/evaluation/treatment in the past and will be providing records, please complete the Release to Disclose Confidential Information Form, #6, and return directly to those providers.*
1. Consent for Healthcare Operations: PDF
2. Child Development Questionnaire: PDF
3. Consent to Treatment: PDF
4. Privacy Policy Acknowledgement and Consent Form: PDF
5. Release to Disclose Confidential Information*: PDF
6. Child Info Form: PDF
7. General Financial Policy – READ ONLY
Speech/Language New Client Packet:
If you have been seen for consultation/evaluation/treatment in the past and will be providing records, please complete the Release to Disclose Confidential Information Form, #6, and return directly to those providers.*
1. Consent for Healthcare Operations: PDF
2. Child Development Questionnaire: PDF
3. Speech Development Questionnaire: PDF
4. Consent to Treatment: PDF
5. Privacy Policy Acknowledgement and Consent Form: PDF
6. Release to Disclose Confidential Information*:PDF
7. General Financial Policy – READ ONLY
9. Speech Language Benefit Check Information – READ ONLY
Adult Packet:
If you have been seen for consultation/evaluation/treatment in the past and will be providing records, please complete the Release to Disclose Confidential Information Form, #5, and return directly to those providers.*
1. Adult Information Form: PDF
2. Consent for Healthcare Operations: PDF
3. Patient Health Questionnaire: PDF
4. Consent to Treatment: PDF
6. Privacy Policy Acknowledgement and Consent Form: PDF
7. Release to Disclose Confidential Information*:PDF
8. General Financial Policy – READ ONLY
Returning Client Packet:
2. Consent for Healthcare Operations: PDF
3. Consent to Treatment: PDF
4. Privacy Policy Acknowledgement and Consent Form: PDF
5. Release to Disclose Confidential Information*:PDF
6. Child Info Form: PDF
7. General Financial Policy – READ ONLY
Please send questions or comments to webmaster@childrensprogram.com