Forms

Please complete the appropriate forms prior to your appointment.  Forms can be either printed, completed and brought to the intake appointment or emailed to us at info@pcsmn.com.

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Be sure to bring your health insurance card to the appointment.

Printable Forms

For medication management appointment with Dr. Bartz:

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• Medication Management Registration Packet- Child/Teen

• Medication Management Registration Packet- Adult

• Medication Management Release and Exchange of Information

Fillable Forms

Coming soon!

Provider Referral Form

Click Here

For a psychotherapy or neuropsychological assessment appointment:

Printable Forms

• Registration Packet–Child

• Registration Packet–Teen

• Registration Packet–Adult

• Release and Exchange of Information (for your physician, school, and any other providers)

• Teacher Rating Scales (ask 1-2 teachers who know your child well to complete these scales)

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Fillable Forms

To complete, after clicking on the appropriate link below, click the Download button and choose “Open with Adobe Acrobat” and save to your desktop before sending.

• Registration Packet–Child

• Registration Packet–Teen

• Registration Packet–Adult

• Release and Exchange of Information (for your physician, school, and any other providers)

• Teacher Rating Scales (ask 1-2 teachers who know your child well to complete these scales)

For Telemedicine Appointments

Printable Forms

• Telemedicine Consent

Online Forms

• Telemedicine Consent

For Your BE-Care (Behavioral Express Care) appointment

• Registration Packet

The following forms are for your review (No need to bring to the appointment)

• Privacy practices

• Financial policies

• Cancellation policy

• Child confidentiality policy

• Services Contract

• Telemedicine Procedures