(509) 891-7867
(509) 922-0984 (fax)
2310 N. Molter, Ste 105
Liberty Lake, WA 99019
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Forms
 

Downloads


Patient Intake Information

Please complete this document and return it as soon as possible in order to schedule an appointment with Dr. Wirthlin.


Background Information

Your medical, educational, and developmental history. Please complete and bring this document to your first appointment.


Consent for Release of Confidential Mental Health/Substance Abuse/Health Records

If you have seen another therapist or psychiatrist, we are interested in learning how it went, but we need your consent to get those records.


Integrated Health and Behavior, Ltd. Notice of Privacy Practices

Basic HIPAA form.



Consent for Release of Confidential Mental Health/Substance Abuse/Health Records To Family Members

We will not leave information, even about appointment times, with family members unless you give consent. This form grants us that consent.


Financial Agreement

An agreement covering various fees for services outside normal consultations.