Client Forms

Establishing care at Willow Medical with an MD or therapist:

*Step 1: You must contact us to set up a brief telephone intake to ensure that Willow Medical is the best fit for your needs. Your intake will be reviewed by a provider and we will get back to you as soon as possible

*Step 2: Once you have been accepted as a new patient, we can only reserve an appointment time for you with your provider until Step 3 is completed.

*Step 3: Please complete and submit the Patient Registration Packet (form #1). Once we receive this form, we can then confirm your scheduled appointment.

* Step 4: Please read below to know which forms are relevant for your appointment. We ask that you complete and submit forms one week prior to your appointment.

All Patients
Please use the UPLOAD link below to send us a copy of your insurance card (front and back) and a photo ID. You will be asked to update the Patient Registration Packet on an annual basis.

New Adult Patients for Psychiatry and Therapy
Please review and complete forms 1-11. Answer the questions and push submit when complete. Your documents will be sent to us directly and securely.*

New Adolescent Patients for Dr. Smith
Please complete forms 1-10. Dr. Smith will also have you complete The Child Behavior Checklist (form 12) which will need to be printed and filled out by a parent or guardian. Once completed, you may fax it to 907.222.0754 or if you scan the document, you may use the UPLOAD link below to send it securely.

ALL TRICARE PATIENTS
Tricare requires that certain rating scales be completed at start of treatment, then every 60 days until discharge from treatment. Please complete The Tricare Rating Scales packet (form 13) every 2 months. You may submit the forms directly online, or print the PDF, then fax to 907.222.0754 or use the UPLOAD link below to send it securely.

If you have any questions or need assistance, please feel free to call us at 907.222.0753. Our staff is happy to help.

Establishing care at Willow Medical with an MD or therapist:

*Step 2: Once you have been accepted as a new patient, we can only reserve an appointment time for you with your provider until Step 3 is completed.

*Step 3: Please complete and submit the Patient Registration Packet (form 1). Once we receive this form, we can then confirm your scheduled appointment.

* Step 4: Please read below to know which forms are relevant for your appointment. We ask that you complete and submit forms one week prior to your appointment.

*You can Electronically Submit forms 1-10. PDF button to the right of the forms, can be downloaded, filled out, and send to our office either by email/fax/ or sent using our secure UPLOAD Link below.

Patient Registration Packet

PDF

Release of Information (ROI)

PDF

Telemedicine Consent Form

PDF

Patient Review of Systems (ROS)

PDF

Patient Health Questionnaire (PHQ-9)

PDF

Generalized Anxiety Disorder Scale (GAD-7)

PDF