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.
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
Submit
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
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?
If you answered yes to any question, please elaborate
I declare that the info I’ve provided is accurate & complete
Submit
Credit Card Authorization