Below you will find the forms you need. They are arranged by needs, e.g. all intake forms are grouped together as are all addiction and substance abuse forms, etc. You can save them by clicking the Form and then saving it to your computer or right click the link and choose "save target as."

Please fill them out before coming to you scheduled appointment, and if possible, return them to A Window of Hope Counseling Center 24-hours before you appointment time.

Keep in mind that you can return the forms via email or FAX (970-867-0524). If you return them via email, you should do so securely. If you choose to email them, you can send them safely and securely through the Internet by going to Sendinc at www.Sendinc.com and opening an account.  It’s free and allows you to send information securely. Don't worry about signing the forms if asked for unless you have the electronic means to do so. We will take care of that when you come in.

If you have questions or if you experience any difficulties, please call 970-380-1160 or email us at hwanderson@q.com.

Forms needed for first meeting (Intake)
    Intake Form This forms collects all relevant information regarding contact information, insurance information, family history, marital history and other personal information. Each adult person (18 or older) should fill out one of these.
    Intake Presenting Issue This form collects information about the reason you are seeking therapy and the impact it has upon your life. Each adult (18 and older) should fill out one of these.
   

Intake Medical History

This form collects information about your medical history. This is to be filled out by/for the client.
    Intake Medicaid Client's Rights

This form should be signed by Medicaid patients only. It informs Medicaid patients of their rights as well as providing information on Advanced Directives and Well-Child Exams (EPSDT).

    Permission for Minors This form must be signed by the parents/caretakers of the child (17 & Younger) before they can receive care from A Window of Hope Counseling Center and its staff. If you are divorced and have joint custody, both parents must sign the form. If you have sole custody of your child/children, you must produce the court document stating that you have sole custody of your child at the time of the first meeting (intake). Include the name of each child you wish to be seen.
    Release of Information If you want A Window of Hope or its staff to share information with anyone not listed on the "Informed Consent" signed at intake, you must first sign a release of information form, which stipulates who the information is to be sent to or received from and the reason for doing so. A separate form must be filled out for each person/institution for which information is to be shared.
    Adult Symptom Inventory This form is designed to indicate possible DSM-IV (Diagnostic and Statistical Manual of the American Psychiatric Association) issues to facilitate an accurate diagnosis of your condition. Please fill it out as accurately and truthfully as possible. It is used for persons 18-years of age and older and one form should be filled for each adult attending the session.
    Child Symptom Inventory Like the adult symptom inventory, this form is intended to identify possible mental health issues for children. It is a longer form than the adult symptom inventory and should be filled by the parent/caretaker of the child. Depending upon the child's age, the parent/caretaker should consult the child to help them fill out the first 55 questions, the remainder to be filled out they parent/caretaker only. One form should be filled out for each child attending the session.
       
  ADHD (Attention Deficit Hyperactivity Disorder)
    Adult ADHD Self-Report Scale Symptom Checklist This is an 18-item self-report inventory used to screen for ADHD in adults.
    Vanderbilt ADHD Assessment Scale - Parent Form For an ADHD diagnosis to take place, these behaviors must be apparent in two independent environments. Normally this is at home and at school. This form is designed for parents/caretakers to assess their child's behaviors at home. Each parent/caretaker should fill out one of these forms.
    Vanderbilt ADHD Assessment Scale - Teacher Form For an ADHD diagnosis to take place, these behaviors must be apparent in two independent environments. Normally this is at home and at school. This form is designed for teachers to assess the child's behaviors at school. Each of the child's teachers should fill out one of these forms.
       
  Alcohol and Substance Abuse Forms
    AUDIT This is the Alcohol Use Disorders Identification Test. It will test whether or not a person has a problem with alcohol and if so, to what extent. If you filled out the Adult Symptom Inventory, you will recognize some of these questions, but should completely fill out the AUDIT even though you may have answered on the Adult Symptom Inventory.
    MAST Similar to the AUDIT, the MAST indicates whether or not a person has a problem with alcohol and if so, to what extent.
    NIDA The NIDA-Modified ASSIST was adapted from the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), developed, validated, and published by the World Health Organization (WHO) as an effective screening tool for identifying substance use. It generates a substance involvement score that suggests the level of intervention needed.
       
  Anxiety, Obsessive-Compulsive Disorder (OCD) and Posttraumatic Stress Disorder (PTSD)
    Children's Yale-Brown Obsessive-Compulsive Scale - Parent Report The Children's Yale-Brown Obsessive-Compulsive Scale - Parent Report is a version of the original clinician-administered CY-BOCS that is designed to be completed by the parent. It is a 10-item scale of pediatric Obsessive-Compulsive Disorder symptoms and severity.
       
    GAD-7 The GAD-7 is a 7-item self-report measure screening for the presence and severity of generalized anxiety disorder.
    PTSD Checklist (PCL-C) The PCL-C is a self-report screening for PTSD with 17-questions relating to the 17 DSM-IV criteria for PTSD.
    SCARED-child The SCARED-child is a 41-item, self-administered scale that aids in the diagnosis of panic disorder/significant somatic symptoms, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and significant school avoidance.
    SCARED-parent The SCARED-parent is a 41-item, parent/other administered scale that aids in the diagnosis of panic disorder/significant somatic symptoms, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and significant school avoidance.
       
  Depression, Mood Disorders and Suicidal Ideation
    Johns Hopkins Depression Checklist for Children (HDCL-C) The Johns Hopkins Depression Checklist for Children (HDCL-C) is a 38-item checklist used to determine depression in children. This is an objective measure completed by the parent and has been shown to be sensitive when used to screen for depression, showing change over time.
    Iowa Personality Disorder Screen (IPDS) The IPDS is an 11-item screening instrument used to evaluate Personality Disorders present or absent in the psychiatric outpatient clinic setting.
    Patient Health Questionnaire 9 (PHQ-9) The PHQ-9 is a 9-item self-report scale consisting of the depression-related items from the Patient Health Questionnaire.
       
If you do not see the Form you need, please email us at hwanderson@q.com.