Delivering Competent & Caring Psychological Services
Consultation Supervision and Training
Kimberly Y. Campbell, Ph.D.
Crystal L. Barksdale, Ph.D., MPH
Dionne Smith Coker-Appiah, Ph.D., MAEd, NCC
GiShawn A. Mance, Ph.D.
Policies & Procedures
Helpful Links & Info
For your convenience, below are forms that you can complete prior to your first appointment. Feel free to download them, fill them, print them out and email them to your designated clinician or bring the completed printed form with you to the first appointment. It will be necessary for clients to read and sign informed consent for treatment when they arrive for their first visit.
When you download a form(s) to be filled in, first save the unfilled form(s) to a file(s) on your computer with a new name which is the original form name followed by your first name and last name (e.g. <Form Name>_Nancy_Smith.pdf). Most browsers do not support digital signatures. Leave the browser and open the downloaded form(s) using Adobe Acrobat Reader. Fill in each of the fillable fields by tabbing between them or clicking on them with the mouse. Don't worry if it appears your input will not fit keep typing and the form will accept everything you type. After finishing filling in the form, please email it back to clinician you are working with. If the form has digital signatures and you are not familiar with digital form signing, click on the detailed instruction file below which opens up a new browser tab to describe how to create a digital signature.
Instructions for creating a digital ID
(Click on any form to download)
Teletherapy Consent Form
Fee Agreement Form
Collateral Consent Form
Adult Intake Form
Child Intake Form
Authorization for Release of Information
Admissions Testing Intake Form
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