Midwest Center for Personal and Family Development

New Client Forms

Before arriving for your first appointment

Before arriving for your first appointment, please print and complete the appropriate forms on this page. To help expedite your appointment, please bring the completed forms with you. If you are unable to complete the forms, please arrive 30 minutes early for your initial appointment so you can complete the forms at our office.

All clients must complete the following two forms:

1. Client Registration Form.PDF
2. Important Signatures.PDF

If the client is 13-17 years old, please complete the following form:

3. Adolescent Information Form.PDF

If the client is younger than 18 years old, a parent/guardian should complete the following form:

4. Parent Questionnaire.PDF

If the client is 18 years old or older, please complete the following form:

5. Adult Client Information Form.PDF

Other Forms:

6. Release of Information.PDF
7. Credit Card on File: Billing Authorization Form.PDF
8. Medica Members Only: Wellness Assessment - Adult.PDF
9. Medica Members Only: Wellness Assessment - Youth.PDF

Forms

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Policies

Important information about your rights and responsibilities in relation to your health care.

Before arriving for your first appointment

All clients must complete the following two forms:

If the client is 13-17 years old, please complete the following form:

If the client is younger than 18 years old, a parent/guardian should complete the following form:

If the client is 18 years old or older, please complete the following form:

Other Forms:

FOR NEW CLIENTS

FOR RETURNING CLIENTS

FOR PHYSICIANS / PROFESSIONALS