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DPS Forms

New Patient Intake Consent Forms

If you are a new patient please choose either New Adult Patient or if you are filling out these forms for you child under 14 please choose New Child Patient. Please make sure you have reviewed the consent forms before you submit by clicking on "view terms of use." If you have not scheduled an appointment yet, plesse call the office before filling out these forms.

New Patient Request Form
How would you like to receive therapy?
Have you scheduled your first session with our office?

Thank you. We will be in touch soon!

Patient Health
Questionnaire (PHQ-9)

Over the last two weeks, how often have you experienced any of the following?

Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Feeling tired or having little energy
Trouble falling or staying asleep, or sleeping too much
Poor appetite or overeating
Feeling bad about yourself, that you are a failure, you have let yourself/your loved ones down
Trouble concentrating on things, such as reading the newspaper or watching tv
Moving/speaking slowly, or being figety/restless and people have noticed
Thoughts that you would be better off dead, or of hurting yourself

Thanks for submitting!

New Patient
Gender

Thanks for submitting! We have received your documents.

Release of Information

Release of Information

hereby authorize:  

 

Delaware Psychological Services 

16287 Willow Creek Rd. 

Lewes, DE 19958 

302-703-6332 

 

To release and/or obtain, the following information  

  • Mental health and medical history, including diagnosis 

  • Records of outpatient treatment 

  • All diagnostic, psychological assessment 

  • Academic records including grades and standardized testing scores 

This information is to be released for the following purpose(s): 

  • Treatment planning & coordination of behavioral health services 

  • Third party billing 

  • At the request of the individual, parent or authorized agent 

  • Forensic Evaluation – I understand that my authorization to release the results of the evaluation may present favorable or unfavorable implications related to the assessment findings and/or recommendations.  I have been informed of the risks pertinent to participation in a forensic evaluation during my initial appointment.   

You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "Submit" you consent to be legally bound

Thanks for submitting!

CAGE-AID Questionnaire
Substance Use Screening

When thinking about drug use, include illegal drug use, and the use of prescription drug other than prescribed:

Have you ever felt that you ought to cut down on your drinking or drug use?
Have you ever felt bad or guilty about your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Thanks for submitting!

Credit Card Authorization

Credit Card Authorization

Thanks for submitting!

Medication Refill Request

Medication Refill Request

Note the following before submitting this form:

 

Refills for controlled substances may require an appointment. Please allow up to 72 hours for these refill requests to be processed. For all noncontrolled medication refill requests, allow up to 48 hours for processing.

 

If you have not been seen by your prescriber within 3 months, call the office to schedule an appointment for your medication to be refilled.

 

To verify that your prescription has been filled, please contact your pharmacy directly. If after 48 hours your script has not been filled, you can email info@dps-wellness.com or call our prescription refill request line at (302) 727-0168

 

Thank you for your request. We will do our best to process your request withing 72 hours of submission.

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