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Phone: (601) 408-7203
(601) 544-8935
Email: dan@yourfamilyclinic.com

Your Family Clinic Client Papers to Download

We put this page together to help our clients have easier access to the documents we use in our Private Practice.

To be completed prior to the First Session

Please just choose one of these....

  • Social History for Children and Adolescents in PDF format
  • Adult Social History in Word format
  • Social History for Military Personnel in Word format

    Compelete each of these....

  • Demographic Information in Word format
  • Consent for Treatment in Word format
  • Client's Rights and Responsibilities in Word format

    This one is needed when we do a Psychological Evaluation ....

  • What School Records we will need for Testing Children and Adolescents in Word format

    HIPPA Information

  • Consent for Treatment in Word format
  • Client's Rights and Responsibilities in Word format

    Miscellaneous

  • Release of Information in Word format
  • Release of Information from the School in Word format
  • Release of Information to Medicaid in Word format
  • Release of Information to Tricare in Word format
  • Release of Information to Youth Court in Word format

    Please feel free to print the appropriate forms, complete them and send them to us. You can bring them the day of your first appointment, Email them to our receptionist, or send them to our business office at: Your Family Clinic LLC, 67 Mars Hill Road, Petal, MS 39465