Patient Forms
You can either complete the forms directly from the links provided below or you can download the forms and fill them out at home. If you download and complete the forms at home you can bring them with you to the appointment or email them to our office at cahopewell@cahopewell.com.
If you have any questions about the forms please feel free to contact us by phone or by email, and we will be happy to assist you. You can contact us by phone at 817-862-7482. You can contact us by email at cahopewell@cahopewell.com.
Formularios del Paciente
Puedes completar los formularios directamente desde los enlaces que encontrarás a continuación o descargar los formularios y rellenarlos en casa. Si descargas y completas los formularios en casa, puedes llevarlos contigo a la cita o enviarlos por correo electrónico a nuestra oficina en cahopewell@cahopewell.com.
Si tiene alguna pregunta sobre los formularios, no dude en contactarnos por teléfono o correo electrónico, y estaremos encantados de ayudarle. Puedes contactarnos por teléfono en el 817-862-7482. Puedes contactarnos por correo electrónico en cahopewell@cahopewell.com.
New Patient Packet (Paquete de Paciente Nuevo)
All patients are required to fill out the appropriate New Patient Packet along with the appropriate Assessment/Evaluation Intake Form. Both forms are available below. Adult (age 18 or older) and Children (age 17 or younger). The Adult New Patient Packet must be signed by the patient or the patient’s Medical Power of Attorney (MPOA). A copy of the current MPOA must be provided to our office. The Children’s packets must be filled out by the parent, legal guardian, or MPOA. A copy of the current legal guardianship, or MPOA must be provided to our office, or any other current relevant legal documents established by a court granting custody and all decision making privileges of a patient (child or adult). If the above current legal documents are not provided to our office, any documents signed by another party on the patient’s behalf will NOT be accepted.
If you need our office to release your records or your child’s records to a third party and you did not fill out the release form in the New Patient Packet or if you need our office to release your records to a third party that you did not previously include on the release form, then please scroll down and fill out and sign the Release of Information Authorization form and submit that to us. For all third party signers, a current copy of the MPOA, legal guardianship, or other legal documents as described above must also be submitted to us with this request, if our office does not currently have it on file, before any records will be released.
Todos los pacientes deben rellenar este paquete junto con uno de los formularios de evaluación adecuados.
If you are unable to complete the new patient intake from the link above please download the form below, fill it out and bring it with you to the appointment or send it to cahopewell@cahopewell.com.
Si no puedes completar el paquete de paciente nuevo desde el enlace anterior, por favor descarga el formulario de abajo, relleno y llévalo contigo a la cita o envíalo a cahopewell@cahopewell.com.
Assessment/Evaluation Intake Form - Adults (Entrevista de Adultos)
Si tienes 18 años o más, por favor rellena este formulario de ingreso.
Assessment/Evaluation Intake Form - Children (Entrevista de Menores para padres)
If you are a parent or legal guardian of a child age 17 or younger, please fill out this intake form. Please note that we require children to be at least 6 years of age.
Si eres padre de un niño de 17 años o menos, por favor rellena este formulario de admisión. Ten en cuenta que exigimos que los niños tengan al menos 6 años de edad.
Release of Information Authorization Form (Formulario de Autorización de Divulgación de Información)
If you would like your report sent to another individual and/or organization, please fill out this form and email to: cahopewell@cahopewell.com
Si desea que su informe se envíe a otra persona y/o organización, por favor rellene este formulario y envíe un correo electrónico a: cahopewell@cahopewell.com
If you are unable to complete the release of information form from the link above please download the form below, fill it out and bring it to the office in-person or send it to cahopewell@cahopewell.com.
Si no puedes completar el Formulario de de Autorización de Divulgación de Información desde el enlace anterior, por favor descarga el formulario de abajo, relleno y llévalo a la oficina en persona o envíalo a cahopewell@cahopewell.com.