Practice Information Office Locations and Maps Scheduling Appointments Before Your First Visit Emergency Contact
Additional Information Additional Links Community Supports Document Downloads E-Mail Table of Contents
George J. Joumas, M.A., L.P.C.
Forms and Document Downloads
These files are in PDF Format (Adobe Acrobat)
Download a free copy of Acrobat Reader from their website first if you do not have this program.
Forms and Documents for:
Joumas Consulting
4545 East Shea Blvd., Suite 112
Phoenix, Arizona 85028
This packet includes:
Personal Data Sheet, Informed Consent for Treatment, Personal Intake / History (2 pgs), Authorization for Release and / or Exchange of Information. (Adult patients need to fill out all these forms (you may skip the authorization form until you meet with me)).
Intake
Packet for Children & Adolescent
This packet includes:
Personal Data Sheet, Informed Consent for Treatment, Consent for Treatment of Minor, Child / Adolescent Developmental History (9 pgs), Authorization for Release and / or Exchange of Information. (Parent (s) need to fill out all these forms (you may skip the authorization form until you meet with me)).
EAP
Packet for Contact Managed Care
This packet includes:
Contact EAP (Only for Contact Managed Care EAP) Client Information Form, Contact Consent for Treatment Form, Contact Member's Rights, Contact Client Orientation Form (Patients and / or Parents (s) need to fill out all these forms for each person that will be attending the EAP session.)
Authorization
for Release and / or Exchange of Information blank
form
Forms and Documents for:
Banner Behavioral Health -
Banner Good Samaritan Medical Center
925 East McDowell Road, 4th Floor - Departments of Psychology & Psychiatry
Phoenix, Arizona 85006
This packet includes:
Personal Data / Face Sheet, Office Policy Consent Form, Personal Intake / History (2 pgs), Authorization for Release and / or Exchange of Information. (Adult patients need to fill out all these forms (you may skip the authorization form until you meet with me)).
Intake
Packet for Children & Adolescent
This packet includes:
Personal Data / Face Sheet, Office Policy Consent Form, Consent for Treatment of Minor, Child / Adolescent Developmental History (9 pgs), Authorization for Release and / or Exchange of Information. (Parent (s) need to fill out all these forms (you may skip the authorization form until you meet with me)).
EAP
Packet for Contact Managed Care
This packet includes:
Contact EAP (Only for Contact Managed Care EAP) Client Information Form, Contact Consent for Treatment Form, Contact Member's Rights, Contact Client Orientation Form (Patients and / or Parents (s) need to fill out all these forms for each person that will be attending the EAP session.)
[ Top of Page ]
Practice Information Office Locations and Maps Scheduling Appointments Before Your First Visit Emergency Contact
Additional Information Additional Links Community Supports Document Downloads E-Mail Table of Contents
Site created by George Joumas / Up dated 05/21/2008
© Copyright 2006 Joumas Consulting