Counseling & Therapy Services
for adults and children

Counseling & Therapy Services for adults and childrenCounseling & Therapy Services for adults and childrenCounseling & Therapy Services for adults and childrenCounseling & Therapy Services for adults and children
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  • Treatment
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  • Policy
  • New Client Forms
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  • About

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As of 8/1/2024, I have a limited number of openings during daytime hours (8am-3pm).

Counseling & Therapy Services
for adults and children

Counseling & Therapy Services for adults and childrenCounseling & Therapy Services for adults and childrenCounseling & Therapy Services for adults and children

EN

  • Home
  • Online Referral
  • Treatment
  • Payment & Insurance
  • Policy
  • New Client Forms
  • Contact
  • About

Forms

Looking for a form to download? You’ve found the right spot. To download any of the forms below, simply click on the link to download the PDF.

Click Below to Download the New Client Packet

If you're a new client, please click on the age appropriate INTAKE PACKET

Child- ages 3-18

Adult- ages 18+

Download and complete all of the pages and bring them to your first therapy session.

If you are unable to print out the  documents, you may also send the completed documents via email to me at TTRPS@DrRuthieNorman.com

 To  request a new intake packet to be mailed to a physical address fill out the request form below. 

CHILD INTAKE (pdf)

Download

ADULT INTAKE (pdf)

Download

Please Read The Following Documents Before Your First Appointment

To save time during our first appointment,  click on the age appropriate PDF which includes the following documents. 

  • Notice of Privacy Practices
  • Informed Consent to Treatment
  • Disclosure Statement & Contract Agreement for Services

Any questions can be asked during our appointment regarding the forms to ensure your understanding. 

CHILD 3-18 (pdf)

Download

Adult 18+ (pdf)

Download

Release of info authorization

If I will be coordinating care with additional providers other than your primary care doctor, The Release of Information form should be completed to authorize release of psychotherapy information. Please complete a separate form for each individual who you authorize for me to coordinate with. Examples: school providers, psychiatrist, community providers, extended family members, your emergency contact, etc.).

Release of Info Form (pdf)Download

MEDICAL RECORDS REQUEST

Packet for Medical Records Request (pdf)

Download

Release of Medical Record (pdf)

Download

Release of psychotherapy notes ONLY (pdf)

Download

Additional Forms

The following forms if applicable may require your signature and will be filed into your personal record. All forms will be be reviewed and discussed prior to signing. Please ask any questions or concerns you may have.

Credit Card Authorization (pdf)Download
Safety Plan (pdf)Download
CANS Consent Form (pdf)Download
PCP Communication (pdf)Download

Child Age 11-17 Measures

The following are tools that may be used to further assess your treatment needs and help provide diagnostic clarification. 

CANS ASSESSMENT (pdf)Download
CANS RATING (pdf)Download
Level-1-Measure-Child-Age-11-to-17 (pdf)Download
Level-2-Anger-Child-Age-11-to-17 (pdf)Download
Level-2-Anxiety-Child-Age-11-to-17 (pdf)Download
Level-2-Depression-Child-Age-11-to-17 (pdf)Download
Level-2-Irritability-Child-Age-11-to-17 (pdf)Download
Level-2-Mania-Child-Age-11-to-17 (pdf)Download
Level-2-Repetitive-Thoughts-and-Behaviors-Child-Age-11-to-17 (pdf)Download
Level-2-Sleep-Disturbance-Child-Age-11-to-17 (pdf)Download
Level-2-Somatic-Symptom-Child-Age-11-to-17 (pdf)Download
Level-2-Substance-Use-Child-Age-11-to-17 (pdf)Download

Parent Measure Form Child 11-17

Early-Development-and-Home-Background-Form-Parent-of-Child-Age-6-to-17 (pdf)Download
Level-2-Anger-Parent-of-Child-Age-6-to-17 (pdf)Download
Level-2-Anxiety-Parent-of-Child-Age-6-to-17 (pdf)Download
Level-2-Depression-Parent-of-Child-Age-6-to-17 (pdf)Download
Level-2-Inattention-Parent-of-Child-Age-6-to-17 (pdf)Download
Level-2-Irritability-Parent-of-Child-Age-6-to-17 (pdf)Download
Level-2-Mania-Parent-of-Child-Age-6-to-17 (pdf)Download
Level-2-Sleep-Disturbance-Parent-of-Child-Age-6-to-17 (pdf)Download
Level-2-Somatic-Symptom-Parent-of-Child-Age-6-to-17 (pdf)Download
Level-2-Substance-Use-Parent-of-Child-Age-6-to-17 (pdf)Download
NICHQ-Vanderbilt-Assessment-Scales (pdf)Download

Severity Measure Child 11-17

Severity-Measure-For-Agoraphobia-Child-Age-11-to-17 (pdf)Download
Severity-Measure-For-Depression-Child-Age-11-to-17 (pdf)Download
Severity-Measure-For-Generalized-Anxiety-Disorder-Child-Age-11-to-17 (pdf)Download
Severity-Measure-For-Separation-Anxiety-Disorder-Child-Age-11-to-17 (pdf)Download
Severity-Measure-For-Social-Anxiety-Disorder-Child-Age-11-to-17 (pdf)Download
Severity-Measure-For-Specific-Phobia-Child-Age-11-to-17 (pdf)Download
Severity-of-Acute-Stress-Symptoms-Child-Age-11-to-17 (pdf)Download
Severity-of-Dissociative-Symptoms-Child-Age-11-to-17 (pdf)Download
Severity-of-Post-Traumatic-Stress-Symptoms-Child-Age-11-to-17 (pdf)Download

Adult Measure Tools

Level-1-Measure-Adult (1) (pdf)Download
The-Personality-Inventory-Brief-Form-Adult (pdf)Download
The-Personality-Inventory-Full-Version-Adult (pdf)Download
DAST (pdf)Download
Generalized Anxiety Scale (pdf)Download
PHQ (pdf)Download
PSS-Adult scale (pdf)Download

ACE Screenings

ACE SCREENING 18+ (pdf)Download
ACE-RESILENCE SCREENING TEEN LLC (pdf)Download
ADULT ACE (pdf)Download
Teen-Self-Report-Part-1 & 2 (pdf)Download
PEARLS-Child-Parent-Caregiver 1 & 2 (pdf)Download

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