419.475.4449

Forms

young-adults

Here are some of the forms you'll need to fill out and bring with you for your first appointment (also called an intake).

Authorization to Disclose

Client Consent for Treatment

Health Assessment

Client Service Agreement

Additionally, here are some helpful downloads about a few of our key policies involving treatment - as well as some general insurance information.

Client Rights & Grievance Procedures

Notice of Privacy Practices

Our clinicians sometimes utilize the NICHQ Vanderbilt Assessment Scale to identify Attention Deficit / Hyperactivity Disorder. If your clinician has directed you to do so, please print out the following forms and fill them out according to their instruction. One is for a parent or guardian to fill out, the other is for a teacher to fill out.

Vanderbilt Assessment Scale - Parent Informant

Vanderbilt Assessment Scale - Teacher Informant

Medicaid, most insurances and private pay accepted. For more information, please call us at 419.475.4449

 

Other Harbor Services

Individual and Group Counseling
Community Support Services
Developmental Pediatrics
Child Psychology
Psychiatric Evaluation
School-Based Programs
Psychological Testing
Alcohol and Other Drug Treatment
Vocational & Rehabilitation Services
Career Assessments
Community Based Counseling
Integrated/Primary Care
Parenting Groups
Medication Management
Dual Diagnosis
On-Site Pharmacy
Wellness Education