Intake Packet

Established 1990


Please download and complete the intake card and bring with you to your first appointment. Please read our "Psychologist-Patient Agreement" as we ask for a signature indicating these have been received. Feel free to ask your therapist any questions about the policies.

If you wish for communication between your therapist and primary care physician, please also complete the PCP Release form. If there is anyone else with whom you would like your therapist to obtain or share information (i.e., previous therapist, school, other past or current treating provider), please complete a separate Release of Information form for each organization or individual.

The following surveys ask questions about how you/yourchild felt in the last two weeks. If you are comfortable doing so, please complete and bring with you to your first appointment. If you prefer not to complete the survey at this time, that is also fine.

     Form for Adults

     Form for Children Age 6-17

Documents require Adobe Acrobat Reader®.


Tiverton Psychological Services
2128 Main Road
Tiverton, RI 02878730

P: 401.624.9972
F: 401.624.1452

© 2009, Tiverton Psychological Services