Forms
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Client History and Prescreening Assessment
Please click the link below or copy and paste it into your browser and fill out the form. Once you click submit it will be routed to me in a Federal Privacy and HIPAA compliant format for processing.
I will contact you in the order in which I receive this form. If I currently have a waiting list you will be added accordingly.
Please click the link below
https://docs.google.com/forms/d/e/1FAIpQLSeb6krVovqwvROLv_E4Ab7733vuDEB_khBQSclTV1T7l9AD0Q/viewform?usp=sharing
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EBT Client Initial Intake
Please click the links below or copy and paste it into your browser and fill out the forms. Once you click submit it will be routed to me in a Federal Privacy and HIPAA compliant format for processing.
I need all of this information (Intake Form, ID, and Insurance card(s) pictures – front and back) back 48 hours before your appointment. Thank you.
I am located in Kodak, TN. My phone number is 865-851-1414 claudia@ebtherapy.org
Please click the link below
https://docs.google.com/forms/d/e/1FAIpQLSex7dXD1p0eMvnfN8-q6BW1gX0ylngLWBzqsXzF2PfF0Rl-vw/viewform?usp=sharing
____________________________________________________________________________________
Client History and Prescreening Assessment
Please click the link below or copy and paste it into your browser and fill out the form. Once you click submit it will be routed to me in a Federal Privacy and HIPAA compliant format for processing.
I will contact you in the order in which I receive this form. If I currently have a waiting list you will be added accordingly.
Please click the link below
https://docs.google.com/forms/d/e/1FAIpQLSeb6krVovqwvROLv_E4Ab7733vuDEB_khBQSclTV1T7l9AD0Q/viewform?usp=sharing
____________________________________________________________________________________
EBT Client Initial Intake
Please click the links below or copy and paste it into your browser and fill out the forms. Once you click submit it will be routed to me in a Federal Privacy and HIPAA compliant format for processing.
I need all of this information (Intake Form, ID, and Insurance card(s) pictures – front and back) back 48 hours before your appointment. Thank you.
I am located in Kodak, TN. My phone number is 865-851-1414 claudia@ebtherapy.org
Please click the link below
https://docs.google.com/forms/d/e/1FAIpQLSex7dXD1p0eMvnfN8-q6BW1gX0ylngLWBzqsXzF2PfF0Rl-vw/viewform?usp=sharing
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Assessments
ACEs Childhood Trauma Assessment
ASRS ADHD Assessment
CSSRS Suicide Rating Scale Assessment
Suicide Safety Plan
No Harm Agreement
MDQ Mood Disorder Assessment
PCL-5 PTSD Assessment
PHQ-9 & GAD-7 Depression & Anxiety Assessments
Consents
Consent to Share of Information
Revoke Consent to Release Information
Handouts
Emotional Self Rescue (ESR)
Don't Grope Me
What it's like to be adopted
Empath / Inner Child Healing
5 destructive fantasies empaths have after the narcissist has left
(copied from Vitalmind psychology)
Misc
EBT Agreement
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Notice of Privacy Practices for Protected Health Information and Health Information Portability and Accountability Act (NPP & HIPAA)
____________________________________________________________________________________
ACEs Childhood Trauma Assessment
ASRS ADHD Assessment
CSSRS Suicide Rating Scale Assessment
Suicide Safety Plan
No Harm Agreement
MDQ Mood Disorder Assessment
PCL-5 PTSD Assessment
PHQ-9 & GAD-7 Depression & Anxiety Assessments
Consents
Consent to Share of Information
Revoke Consent to Release Information
Handouts
Emotional Self Rescue (ESR)
Don't Grope Me
What it's like to be adopted
Empath / Inner Child Healing
5 destructive fantasies empaths have after the narcissist has left
(copied from Vitalmind psychology)
Misc
EBT Agreement
____________________________________________________________________________________
Notice of Privacy Practices for Protected Health Information and Health Information Portability and Accountability Act (NPP & HIPAA)
____________________________________________________________________________________