nav bar background

         888-725-4642

Join Our Mailing List                                                            

 

New Client Forms

The following forms are provided for Meier Clinics clients who would like to print and complete them prior to their appointment.  Please note:  you may still need to sign or complete additional forms at the time of your appointment.

 

Please print all national forms and then check if any are listed under the state and program for which you are receiving care. 

 

If you have any questions about the forms or need assistance in completing these forms, contact the office where you made your appointment.  We will also be happy to answer any questions when you come in for your appointment, or give us a call at 888-725-4642.

 

All forms are provided in Adobe Acrobat.  If needed, you may download this program for free at: get.adobe.com.

National Forms

  • Notice of Privacy Practices and Client Rights
    • For your information only
  • Patient Registration
    • Please complete all applicable sections
  • Release of Information
    • Carefully and fully complete this form if you want information about your care provided to another person.  Please note that there may be a charge for the copying and processing of medical records.  Your records are confidential and will not be provided to anyone without your written consent, except as allowed by federal and/or state law.

EN ESPANOL

Florida

ILLINOIS

Outpatient       

Day Programs (Adult and "Breakaway")

(do not complete if only seeing a psychiatrist)

The following form is for clients 15 years and younger.

(to be completed by parent/guardian for clients 15 years and younger - do not complete if only seeing a psychiatrist/M.D.)

Testing

Neuropsychological Testing

MARYLAND

PENNSYLVANIA

TEXAS

Outpatient       

Day Programs (Adult, Sexual Addictions)

(complete all applicable sections)

 

VIRGINIA

 

The following form is for clients 15 years and younger.

WASHINGTON

 

The following form is only for clients 15 years old or younger.

(to be completed by parent or guardian)
 

IMPORTANT NOTES: 

  • Illinois law requires that clients 12 years old and up sign the form; the parent's signature is not accepted in lieu of the adolescent's signature. 
  • Texas law requires that clients 16 years and up sign the form; the parent's signature is not accepted in lieu of the adolescent's signature. 

 

Financial Disclosure

 

If you do not have insurance coverage and have been informed that you qualify for discounted care, you must complete this form and provide the required documentation.  Discounts are subject to review and may be changed or discontinued if your financial situation changes or if you obtain health insurance coverage.