Boise Psychological Services

Patient Forms

Please print and sign all documents required and bring them with you to your first appointment.

Forms Required for All Counselors

  1. Symptom Measure Form - Please print and complete the appropriate form below.
    Self-Rated Level 1 Cross-Cutting Symptom Measure - Adult
    OR
    Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure - Child Age 6-17
  2. Patient Intake Form (PDF Fill-in Form, revised 12.13.2016) Use the FREE Adobe Reader to fill in form fields. After completion, please print, sign and bring this form to your first appointment.
  3. Therapy and Description of Services (PDF document, revised 12.13.2016) Please print, sign and bring this form to your first appointment.
  4. HIPPA Notice of Privacy (PDF document, revised 12.13.2016) Please read.
  5. HIPPA Acknowledgement of Receipt of Notice of Privacy (PDF document, revised 12.13.2016) Please print, sign and bring this form to your first appointment.

Additional Forms for Patients of Michael J. Eisenbeiss, PhD.

  1. Consent and Agreement for Psychological Testing and Evaluation (PDF document, revised 12.13.2016) Please print, complete form, sign and bring it to your appointment.
  2. Financial Agreement for Testing (PDF document, revised 12.13.2016) Please print, sign and bring this form to your appointment.

 

 
 

Boise Psychological Services
315 N. Allumbaugh Street
Boise, Idaho 83704

Phone: 208.376.3546

Fax: 208.376.9792