Patient Forms

For New Patients:

***As a new patient, please also review our page related to COVID-19 here. We are attempting to digitize forms ASAP; this page will be updated as necessary to assist.***

1. Policy forms are contained within our patient portal, OnPatient; please set your account up, enter the requested information, and complete these prior to your first appointment, as directed by our staff.

  • If you cannot complete this beforehand, please see the warning below regarding coming to your first appointment early.

  • For patients under the age of 13, a parent or guardian will need to digitally sign these forms; patients 13 and older will sign for themselves.

  • Patients ages 13 to 17 only will need to complete and bring in the form below:

Adolescent consent form

2. It is also required that you print, complete, and bring the following new patient questionnaire with you to your first appointment.

  • If you cannot complete this beforehand, you will need to arrive at our office at least 30 minutes prior to your scheduled appointment time to complete these. If you cannot do so, you may be charged a fee and/or need to reschedule as mentioned in the policies.

  • When meeting with Dr. Moore via telehealth, you will need to forward a completed copy of this via the OnPatient portal before the start of your appointment.

Complete the below packet:

Intake questionnaire

Please note: individuals 13 years of age and older should fill the above packet out primarily on their own, with assistance from parents/guardians if requested.  Also, these packets contain a blank release of information (ROI) form; generally, you will want to complete that for any talk therapists, primary care providers, and recent psychiatric providers.  If any further ROIs might be useful, this can be discussed during your first appointment.

Other forms:

Telemedicine consent form

FYI only; our telehealth platform will have you provide consent electronically.

Release of information

Card-on-file authorization

©2020 BY LEE MOORE, ARNP, PLLC dba SPECTRA INTEGRATIVE PSYCHIATRY

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