Patient Intake Forms

Please fill out the packet of forms and fax them to us at 1 (206) 686-1268 as soon as possible. The most important form is the Authorization to Release Health Care Information. We will use this to obtain your medical records. Once this is completed we can schedule an appointment at your earliest convenience. If you have any questions or concerns, please give us a call at 1 (206) 686-1266. Thank you!

Download Forms

This packet contains:

Patient Information Form

Basic information and contact methods

Patient Health Questionnaire

Treatment history, family medical background, and medications

Authorization to Release Health Care Information

Provides us access to patient information from other healthcare providers

Lifespring Acknowledgement

Etiquette and standard clinic procedures

Notice of Privacy Practices

Acknowledgement of privacy practices and patient privacy rights

Patient Consent for Research and Publication Form

Consent to include your anonymized treatment information and results for research