Patient Forms

Paperwork, kept quiet and simple.

Your intake packet is sent securely once your first appointment is scheduled. The documents below are listed so you know exactly what to expect.

Before your first visit
  • Patient Intake Form
  • Consent to Mental Health Services
  • Notice of Privacy Practices (HIPAA)
  • Consent for Telehealth Treatment and Services
  • Treatment agreements
  • Consent for Psychotropic Medications
  • Controlled Substance & Stimulant Agreement
  • Client Safety Contract
  • Adult ADHD Self-Report Scale (ASRS v1.1)
  • Administrative requests
  • Records Release Authorization
  • Statement for Insurance Reimbursement
  • School / Work Excuse Request
  • Medical Waiver Form
  • Need a document before your visit, or a copy of something already signed? Ask and it will be sent to you securely the same week.

    Practice Policies

    Clear expectations, both ways.

    Cancellation

    Appointments cancelled with less than 24 hours' notice, or missed without notice, may be billed at the full visit rate. Life happens — tell us as early as you can and we will work with you.

    Medication refills

    Refills are handled during scheduled appointments. Please request them at least three business days in advance and keep follow-up visits current so prescriptions are never interrupted.

    Controlled substances

    Stimulants and benzodiazepines are prescribed under a written agreement, with periodic review, prescription-monitoring checks, and in-person or video follow-up as clinically required.

    Communication & privacy

    Messages are answered within one business day. This practice is not an emergency service — if you are in crisis, call or text 988, or go to your nearest emergency department.

    A final word

    Your mind deserves thoughtful care.

    Samara

    Behavioral Health & Wellness

    © 2026 Samara Behavioral Health & Wellness