NEW CLIENT FORMS BY LOCATION

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 forms listed under the state and program for which you are receiving care.  If you have any questions about the forms you should use or need assistance in completing these forms, contact the office where you made your appointment.  A list of clinics, including phone numbers and addresses, can be accessed on our Locations page.  We will also be happy to answer any questions when you come in for your appointment.

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

CALIFORNIA

• Client Agreements and Acknowledgements/Child-Adolescent Consent for Treatement/Divorce-Legal Separation Collection Policy (first section required for all clients / second and third section as applicable)    
• Notice of Privacy Practices and Client Rights (for your information only)
• Patient Information and Consent to Treatment
• Patient Registration (complete all applicable sections)

ILLINOIS

KANSAS

• Client Agreements and Acknowledgements/Child-Adolescent Consent for Treatement/Divorce-Legal Separation Collection Policy (first section required for all clients / second and third section as applicable)  
• Notice of Privacy Practices and Client Rights (for your information only)
• Patient Information and Consent to Treatment
• Patient Registration (complete all applicable sections)

MARYLAND

• Client Agreements and Acknowledgements/Child-Adolescent Consent for Treatement/Divorce-Legal Separation Collection Policy (first section required for all clients / second and third section as applicable)  
• Notice of Privacy Practices and Client Rights (for your information only)
• Parent/Legal Guardian Questionnaire/Psychosocial (to be completed by parent/guardian for clients 15 years and younger)
• Patient Information and Consent to Treatment
• Patient Registration (complete all applicable sections)
• Psychosocial Assessment - Age 16 and Above 

PENNSYLVANIA

• Client Agreements and Acknowledgements/Child-Adolescent Consent for Treatement/Divorce-Legal Separation Collection Policy (first section required for all clients / second and third section as applicable)  
• Notice of Privacy Practices and Client Rights (for your information only)
• Patient Information and Consent to Treatment
• Patient Registration (complete all applicable sections)
• Psychosocial Assessment - Age 16 and Above

TEXAS

VIRGINIA

WASHINGTON

NATIONAL FORMS

The following forms are for use at all Meier Clinics locations.  If you have any questions, please contact us at

888-725-4642.

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

Authorization for Use and Disclosure of Protected Health 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.

Financial Disclosure.  If you do not have insurance coverage and have been informed that you qualify for discounted care, you must complete this form and provide the required documentation.  Discounts are subject to review and may be changed or discontinued if your financial situation changes or if you obtain health insurance coverage. 

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