WellSpring Child and Family Psychology, PC
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FORMS

Welcome!

The following forms must be completed prior to your first appointment. They provide important information about the practice, your rights and responsibilities, and confidentiality. If you would like to print and complete these forms prior to your first appointment, that will allow more time to focus on the things that are most important to you. 

Adult forms:

This group of forms is for anyone 18 years of age and older (unless someone else has legal guardianship of the individual)
WS HIPAA
File Size: 79 kb
File Type: pdf
Download File

WS Informed Consent
File Size: 79 kb
File Type: pdf
Download File

WS Adult Info Form
File Size: 41 kb
File Type: pdf
Download File

Adolescent Forms:

The forms below are for adolescents ages 14 to 17. They must be signed by the legal guardian. The "adolescent consent" form must be signed by both the legal guardian and the adolescent. 
Adolescent Info Form
File Size: 54 kb
File Type: pdf
Download File

WS Informed Consent
File Size: 79 kb
File Type: pdf
Download File

WS Adolescent Informed Consent
File Size: 112 kb
File Type: pdf
Download File

WS HIPAA
File Size: 79 kb
File Type: pdf
Download File

Child Forms:

These forms are for children ages 13 and below. They must be signed/completed by a legal guardian.
Child Info Form
File Size: 54 kb
File Type: pdf
Download File

WS HIPAA
File Size: 79 kb
File Type: pdf
Download File

WS Informed Consent
File Size: 79 kb
File Type: pdf
Download File

SUPPLEMENTAL Forms:

If you would like for us to communicate with anyone else about you or your child (e.g., medical providers; schools; previous providers), please complete the "consent for release" form below and return it to us:
WS Release of Information
File Size: 78 kb
File Type: pdf
Download File

If you would like to use a credit card to make payments, please complete the credit card authorization form below:
WS Credit Card Authorization
File Size: 41 kb
File Type: pdf
Download File

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WellSpring Child and Family Psychology, PC
615 Emancipation Highway, Suite 101
​Fredericksburg, VA 22401
Phone: (540) 693-0096     

Copyright 2014; All Rights Reserved