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 HIPPA |
| WS Informed Consent |
| WS Adult Info Form |
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.
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Child Forms:
These forms are for children ages 13 and below. They must be signed/completed by a legal guardian.
| WS Child Information Form |
| WS HIPPA |
| WS Informed Consent |
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:
| wellspring_consent_for_release.pdf |
If you would like to use a credit card to make payments, please complete the credit card authorization form below:
| wellspring_credit_card_authorization.pdf |