The Keystone Building
Home of NWPR
945 - 11th Ave., Longview, WA




STEP 1: Intake Forms

These forms provide personal and financial information necessary to set up a clinical and billing account. You should select and complete the appropriate form, and bring this in to your first appointment. They may be opened in Adobe Reader and printed on your printer. If you have a recent version of Adobe Reader, the forms may be filled out on your computer and printed on your printer. Please be aware that you cannot save your form that is filled out using Adobe Reader (you need Acrobat Standard or Acrobat Professional to save a form completed on your computer. To download a free version of Adobe Reader, click the Adobe link below.

get adobe acrobat

*Individual Adult Intake
Complete for individuals 18 years or older.

*Child/Teen Intake
Complete this for children up to age 17 years when the child is the primary focus of treatment, including both individual and/or family therapy.

*Couples Intake
Complete when two adults are seeking counseling for relationship issues

STEP 2: Office Policies, Informed Consent, and Privacy Notice

This is a necessary form to download that contains information about the office and protecting your privacy. You will need to read this form and sign the last page. Bring in the last signature page along with the above intake form to your first appointment.

*Office Policies, Informed Consent, and Protecting the Privacy of Your Healthcare Record

Other Forms You May Need

Occasionally, you may be instructed to complete additional forms or tests needed in the course of your evaluation and treatment. Below is a list of these available for your convenience. It is not necessary to download or complete these forms unless specifically instructed.

*Adult Release of Information
This forms allows your provider to communicate with others involved in your care.

*Child Release of Information
This forms allows your provider to communicate with others involved in your child’s care. Use for children under age 18. Young adults 18 and over should use the adult form above.

*Information About Your Neuropsychological Examination
This sheet provides information about what to expect if you are being referred for neuropsychological testing.