Initial Intake FormProvides your basic information so we can get to know you and begin your care with understanding and clarity.
New Client Forms
Your First Step Toward Renewal
Welcome to Mind Rejuvenation. We are honored to support your wellness journey. To help us understand your needs and provide the most personalized care, we ask that all new clients complete the intake forms before your first session. These forms are simple, confidential, and supportive of your goals.
Before Your First Visit
The Forms You Will Need
Download and complete each form before your first visit. Use Open to view the PDF in a new tab, or Download to save a copy to your device.
HIPAA Authorization FormExplains how your health information may be used and shared, and documents your privacy preferences.
Medication Information ListGathers details about your current medications, and those you have tried, to support safe, coordinated treatment.
Financial PolicyOutlines our financial guidelines so you know what to expect regarding payments and billing.
Appointment PolicyCovers our scheduling, cancellation, and attendance expectations to help ensure smooth, consistent care.
Emergency & Crisis PolicyClarifies what steps to take during urgent situations, what qualifies as a crisis, and how to quickly access support when you need it most.
Treatment Consent — Med. ManagementProvides key information about medication based treatment and confirms your consent for Medication Management services.
Telehealth ConsentExplains how virtual appointments work and outlines your rights and responsibilities when receiving care remotely.
ADHD Intake FormCollects attention, organization, and daily-function details to support a thorough ADHD evaluation.
Adult ADHD Self-Report Scale (ASRS)A brief symptom checklist that helps your provider understand how attention and activity challenges show up day to day.
ADHD Differential Diagnosis ScreeningHelps distinguish ADHD-related symptoms from other common contributors such as sleep issues, anxiety, or depression.
Child & Adolescent History FormGathers background, history, and goals so we can better understand your child’s needs before the first visit.
Contact Mind Rejuvenation
Start Your Healing Journey Today
Whether you are ready to book your first visit or simply have questions about our treatments, we are here to help. Fill out our contact form and a member of our team will reach out shortly.
Every step you take toward wellness matters, and we are honored to walk it with you.
Contact us