Initial Assessment Forms

General Instructions for Forms

Please complete the forms online using the online form links below. Please submit them by the evening before our appointment to give me time to look through them before our session. 

All Information that is submitted using the online forms is encrypted and secure to protect your sensitive data.

Initial Assessment Forms

The following forms all need to be completed for our first session:

Assessment Form, the Patient Information Sheet, the HIPAA Privacy Information & Confidentiality Form, the Credit Card Payment Form, Teletherapy Consent Form and any of the Symptom Checklists that are relevant to how you are feeling.

Please click on the links below to complete the forms online through a HIPAA compliant system or by printing, completing by hand and emailing them to (which is an encrypted secure email address).

Assessment Questionnaire Print

Assessment Questionnaire Online form

Patient Information Sheet Print

Patient Information Online form

HIPAA – Privacy of Information Policies Print

HIPAA – Privacy of Information Policies Online form

I use a credit card system through Chase bank that securely keeps your information on file to be accessed for the session fee after each session. This means you do not have to complete the information at every session. I accept Visa & Mastercard. Amex is not accepted at this time.

Credit Card Payment Authorization Form Print

Credit Card Payment Authorization Form Online Form

More information about appointments via telephone or using Google Meet which is a HIPAA compliant video platform can be found on the Telephone or Online Sessions page.

Teletherapy Consent Form Print

Teletherapy Consent Form Online Form

Please complete any of the Symptom Checklists below that are relevant to your symptoms.You do not need to complete all of them unless you feel they all apply to how you are feeling. There are different general checklists and ones that are specifically for pregnant and new parents.

Depression Symptoms Scale PHQ-9 Print

Depression Symptoms Scale PHQ-9 Online Form

Anxiety Symptoms Questionnaire GAD-7 Print

Anxiety Symptoms Questionnaire GAD-7 Online Form 

Trauma Questionnaire Impact of Events Scale Print

Trauma Questionnaire Impact of Events Scale Online Form

If you are pregnant, or up to a year postpartum, please complete the Screening Tests below rather than the PHQ-9 or GAD-7.

Pregnancy & Postpartum Mood Screening Test Print

Pregnancy & Postpartum Mood Screening Test Online Form

Perinatal Anxiety Screening Test Print

Perinatal Anxiety Screening Test Online Form

Trauma Questionnaire Impact of Events Scale Print

Trauma Questionnaire Impact of Events Scale Online Form

Please note that these checklists are part of Dr. Allen’s assessment for new clients and are not meant as a diagnostic tool for people who are not Dr. Allen’s clients. The completed checklist results are only available to Dr. Allen due to HIPAA compliance rules.

Using Medical Insurance Benefits

If you would like me to submit your insurance claim to your insurance company electronically on your behalf please download the Insurance Submission form below.

Alternatively, I can provide you with a monthly statement called a Superbill which is a detailed receipt that you submit yourself and provides all the information insurance companies need to create a claim and you can potentially get some reimbursement.

Insurance Submission Form Print

Insurance Submission Online Form

General Forms

Consent To Communicate With Your Other Healthcare Providers

Please complete the Consent to Release Information Form below if you would like me to be able to communicate or release information regarding your therapy to other doctors or specified family members.

Release of Information Consent Form Print

Release of Information Consent Online Form

Weekly Unhelpful Thought Diaries

An important part of Cognitive Therapy is keeping track of unhelpful thoughts (also called cognitions). Together we will look at where theses types of thoughts come from, how they are holding us back and how to reframe them in a way that improves mood. The Thought Diary can be downloaded below and gives a structured way to identify unhelpful negative thoughts. Side 2 gives a list of questions that help us challenge these unhelpful negative thoughts.

Thought Diary Side 1

Thought Diary Side 2

I am happy to answer any questions you may have either by phone 847 791-7722 or click on the above link.