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Forms

Forms needed for initial visit:

• Intake Form

• IMPORTANT: Insurance Information Form
  • Please fill out at least 3 days prior to your visit and send it to:
    • pra.intake@yahoo.com
    • 1627 Oak Avenue, Suite A, Davis 95616
    • Fax: 530-756-1368
      
      
• Authorization to use Credit Card
  
  
• Initial Client Questionnaire
  
  Optional Forms Requested by Therapist:   
  
  
• Psychotherapy Assessment
  
  
• Biography (New)
  
  
• Trauma Questionnaire
  
  
• Adolescent Dissociative Experience Scale II (A-DES)
  
  
• Child Dissociative Checklist (CDC)
  
  
• Sex and Love Addiction Self Diagnosis
  
  Additional Information and Resources:

• Psychological Assessment

• Child and Adolescent History Form

• Dissociative Experience Scale (DES) Vers. II

• Ten Most Disturbing/Traumatic Memories

• Amen Clinic Anxiety and Depression Type Questionnaire

• Amen Brain System Checklist

• Developmental Stages

 

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