Forms To Be Completed Prior To Your Appointment
Adults
Print out the Adult History questionnaire. Complete each section thoroughly and in detail. Do not skip any section.
Print and complete the Rating Scales and Informed Consent for Telehealth. You do not need to complete the Release of Protected Health Care Information form until the feedback session, and the HIPAA form is for your information only.
If your health insurance is covering your consultation, you will receive a Statement of Account via email that also needs to be signed and returned.
Return the completed documents (Adult History, Rating Scales, Informed Consent for Telehealth, and Statement of Account) via email or fax at least one week prior to your first appointment. Our fax number is 401-782-2653. To send documents via email, scan the documents as PDF files and save them as one attachment (not multiple pages). Printed documents can be easily scanned into PDF files on your phone using the Notes app or other available free apps. Do not send them as photos or JPEG files as these are often difficult to read or to print due to formatting issues. Our email address is info@cnldinc.com.
Young Adults
high school graduates through age 25
Print out the Adult History questionnaire. Complete each section thoroughly and in detail. Do not skip any section.
Print and complete the Rating Scales and Informed Consent for Telehealth. You do not need to complete the Release of Protected Health Care Information form until the feedback session, and the HIPAA form is for your information only.
Please also print the Parent History questionnaire for one or both of your parents to complete independently, from their perspective, along with a second set of Rating Scales for your parent(s) to complete as well.
If your health insurance is covering your consultation, you will receive a Statement of Account via email that also needs to be signed and returned.
Return the completed documents (Adult History, Parent History, two (2) sets of Rating Scales, Informed Consent for Telehealth, and Statement of Account) via email or fax at least one week prior to your first appointment. Our fax number is 401-782-2653. To send documents via email, scan the documents as PDF files and save them as one attachment (not multiple pages). Printed documents can be easily scanned into PDF files on your phone using the Notes app or other available free apps. Do not send them as photos or JPEG files as these are often difficult to read or to print due to formatting issues. Our email address is info@cnldinc.com.
Adolescents 16-18
still in high school
Print out the Parent History questionnaire. Complete each section thoroughly and in detail. Do not skip any section.
Print and complete the Rating Scales and Informed Consent for Telehealth. You do not need to return the Release of Protected Health Care Information form until the feedback session, and the HIPAA form is for your information only.
Please print a second set of Rating Scales for your child to complete, independently of you, from their perspective. Do not send one set of rating scales that you worked on together.
If your health insurance is covering this consultation, you will receive a Statement of Account via email that also needs to be signed and returned.
Return the completed documents (Parent History, two (2) sets of Rating Scales, Informed Consent for Telehealth, and Statement of Account) via email or fax at least one week prior to your first appointment. Our fax number is 401-782-2653. To send documents via email, scan the documents as PDF files and save them as one attachment (not multiple pages). Printed documents can be easily scanned into PDF files on your phone using the Notes app or other available free apps. Do not send them as photos or JPEG files as these are often difficult to read or to print due to formatting issues. Our email address is info@cnldinc.com.
Optional
do not complete unless requested