Forms


Please complete all requested forms before your first visit to The Southfield Center.

All forms can be found below by clicking on the service.

Forms may be securely submitted on-line; however, you also may print the forms and bring them

to your first visit.

Thank you, as always!

  • If you are coming to The Southfield Center for Child Therapy, click here:
  • If you are coming to The Southfield Center for Adult Therapy, click here:
  • If you are coming to The Southfield Center for any other Therapeutic Intervention (ADHD Case Management, Family Therapy, PCIT, Group Therapy, Etc.,), click here:
  • If you are coming to The Southfield Center for Diagnostic Services (Psychoeducational Evaluation, Neuropsychological Evaluation, Academic Update Evaluation, Substance Abuse Evaluation, etc.), click here:
  • If you are coming to The Southfield Center for Speech and Language Services, click here:
  • If you are coming to The Southfield Center for SuperKids, click here:
  • If you are coming to The Southfield Center for Medication Management or Psychiatry, click here:
  • If you are coming to The Southfield Center for Learning Services (EF Coaching, LD Tutoring, Reading Support, Math Support, Transition Services), click here:
  • If you are coming to The Southfield Center for Cogmed Working Memory Training, click here:

Therapy Child

Psychotherapy – Clinical Intake Form – Child

Contract for Psychotherapy Services – Child

Psychotherapy – Consent to Release or Obtain Information

Psychotherapy – HIPAA Privacy Notice

Therapy Adult

Psychotherapy – Clinical Intake Form – Adult

Contract for Psychotherapy Services – Adult

Psychotherapy – Consent to Release or Obtain Information

Psychotherapy – HIPAA Privacy Notice

Behavioral Therapy Services

Behavioral Health Services – Clinical Intake Form

Contract for Behavioral Therapy Services

Behavioral Health Services – Consent to Release or Obtain Information

Behavioral Health Services – HIPAA Privacy Notice

Assessment Services

Assessment and Diagnostic Services – Clinical Intake Form

Contract for Assessment and Diagnostic Services

Assessment and Diagnostic Services – Consent to Release or Obtain Information

Assessment and Diagnostic Services – HIPAA Privacy Notice

Insurance Pre Authorization

Speech and Language Therapy

Speech and Language – Clinical Intake Form

Contract for Speech and Language Services

Speech and Language Services – Consent to Release or Obtain Information

Speech and Language Services – HIPAA Privacy Notice

The Southfield Center for SuperKids

SuperKids Clinical Intake Form

Contract for SuperKids

SuperKids Consent to Release or Obtain Information

SuperKids – HIPAA Privacy Notice

Medication Management or Psychiatry

Medication Management or Psychiatry – Clinical Intake Form – Child

Medication Management or Psychiatry – Clinical Intake Form – Adult

Medication Management or Psychiatry – Consent to Release or Obtain Information

Medication Management or Psychiatry – HIPAA Privacy Notice

Learning Services

Learning Services – Intake Form

Learning Services – Contract Agreement

Learning Services – Consent to Release or Obtain Information

Learning Services – HIPAA Privacy Notice

Cogmed Working Memory Training

Learning Services – Intake Form

Cogmed – Contract Agreement

Learning Services – Consent to Release or Obtain Information

Learning Services – HIPAA Privacy Notice

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