Forms

Initial Intake Form for Adult Clients

This form must be completed prior to your first session. It can be emailed, mailed in or brought in person to your first appointment.
Please see contact page for fax number and email address if needed.

These forms provide your therapist with basic information regarding past medical history, relationships, employment, and presenting concerns. Feel free to omit any questions that you are uncomfortable with or would rather discuss in person. This also allows our administration staff to run your insurance prior to your appointment and establish your co-pay if any. This form is used for private therapy only, not group therapy or for evaluations.

Please see contact page for fax number and email address.

Click here to download form

Initial Intake Form for Minor Clients

These form must be completed prior to your childs first session and by a parent or guardian. It can be emailed, mailed in or brought in person to your first appointment.

These forms provides your therapist with basic information regarding past medical history, relationships, employment, and presenting concerns. This also allows our administration staff to run your insurance prior to your appointment and establish your co-pay if any.
This form is used for private therapy only, not group therapy or for evaluations.

Please see contact page for fax number and email address.

Click here to download form

Release of Information Forms

Authorization for Use or Disclosure of Health Information – Please use this when you would like your treatment file released to another medical provider or attorney.

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Consent to Evaluation and Release – This form will be given to you when you arrive for your evaluation. This allows us to speak to other agencies and/or your attorney about the results of your evaluation.

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Financial Release – Please use this form when you would like another person or agency the ability to discuss financial issues with us on your behalf. This includes making payments to your account.

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ITP Release of Information – General release of information that allows ITM Group to communicate with other agencies, such as medical doctors, universities, insurance companies, and past therapists. Please use this one for Juveniles.

Click here to download form

Theft Fraud Intervention Intake Information

Print form and fill out honestly, then either mail to 225 SW 7th Terrace, Gainesville, FL 32601 or fax to (352) 379-2843. For additional options call the administrative office and speak to Jason Herrell.

Click here to download form

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