You may download and complete all of the forms below and bring all completed forms to your initial appointment or fax to 603-413-4840 or email to intake@psychiatricwellnesscenter.org. If you have any questions regarding any of the forms, you may ask your provider at your appointment. 

Practice Policies

Consent for Treatment and Acknowledgement Agreement Signature Form

Parent/Legal Guardian Consent (Must be completed for patients under age 18)

HIPAA Notice of Privacy Practices

Registration Form

Medical History Form

Credit Card Form

Patient Health Questionnaire

Release Form (Please complete one for Primary Care Physician, current therapist and school if child/adolescent) 

Telebehavioral Health Consent Form (Please complete if you are participating in a Telehealth session)

Telebehavioral Health Safety Plan (Please complete if you are participating in a Telehbehavioral Health session)