Patient Forms

Alabama Psychiatric Services (APS) makes the following forms available for our patients’ use:

Authorization to Release Protected Health Information (QA 25-A) – This document must be completed by any patient requesting APS to disclose information regarding their treatment to any other source outside APS. Usually, this document is signed with a clinician in any APS office. However, we recognize there are times when it may not be convenient for a patient to come to our office for this purpose. The Authorization can be printed and signed outside an APS office, but when doing so, the patient must have this document notarized and send the original to APS. Any patient wishing to have their Protected Health Information disclosed to another source should first discuss it with the clinician providing their treatment.

Authorization to Request Protected Health Information (QA 25-B) – This document must be completed by any patient who wants APS to obtain their Protected Health Information from another medical professional. During the course of treatment, it is often helpful for APS to obtain medical information from another healthcare provider. This is particularly true when a patient has seen another mental health provider in the past. Patients can complete this document in any APS office or can print it from the website and provide it to their healthcare provider whom they would like to share information with APS.

APS Patient Information Form – This document should be completed by all new patients, or in the case of a minor, by their parent/legal guardian, when seeking care at Alabama Psychiatric Services. Please follow the directions on the form, complete in its entirety, and bring to your initial appointment.

Adult Patient Questionnaire (QA 42) – Patients entering treatment at APS may be evaluated by a psychiatrist, psychologist, or master’s level therapist. All adult patients are asked to complete this questionnaire prior to their first appointment. The questionnaire can be printed from our website, and completed by the patient and brought to the initial appointment.

Child/Adolescent Intake Forms

Child / Adolescent Intake Checklist – This document is to be used as a guide for items we ask that parents bring to the first appointment for their child or adolescent. Please pay special attention to the items that are “required,” and ensure that you complete and bring these with you to your initial appointment. Please note that in cases of divorced parents, a custodial parent must accompany the child/adolescent to their initial appointment.

Child/Adolescent Parent Questionnaire (QA 7CA pages 1-4) – APS believes that a parents’ input is vitally important in assessing a child or adolescent. In order to obtain this parent input, APS has developed a Parent Questionnaire. This document can be printed from the website and completed by parents who’ve made an appointment for their child. The completed questionnaire should be brought to the initial appointment. This saves time for the parent and gives you an opportunity to complete the questionnaire in your own environment, allowing you time to carefully consider your responses.

Family Physician Questionnaire (QA – 12CA) – When seeking behavioral health care services for your child or adolescent, it is important to understand that coordination of care with your child’s pediatrician or family physician can be very important. This is particularly true when your child has a health condition for which they have had medical treatment and perhaps are prescribed medication. APS is committed to that coordination of care with your child’s physician. In order to do so, we have developed this Family Physician Questionnaire to be completed by your child’s physician. We ask that if at all possible, you have your child’s physician complete this document and bring with you to the initial appointment in our office. This information will be carefully considered as we evaluate your child. Should you desire, and upon appropriate authorization by you, we will also be glad to provide information to your child’s physician once our assessment is complete.

Child/Adolescent Symptom Assessment & Outcome Measurement – Teacher Form (QA-CA 35b) – APS is committed to the measurement of patient outcomes. We believe that a teachers’ input often is very important in assessing a child or adolescent. In order to obtain this teacher input, APS has developed a Child/Adolescent Symptom Assessment Form for teachers to complete. This instrument allows teachers who spend significant time with the patient, to answer questions regarding their observations of a patient’s symptoms that may be observed in the classroom setting. Parents are encouraged to print this form and give to their child’s teacher(s), have them complete it and return it to the parent. The parent should then bring the completed forms to the initial appointment.