Southeast Institute

Intake Forms for Dr. Peterson's Clinical Practice

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    the Institute

• All New Patients, please download the Patient Notification of Privacy Rights (PDF file) and complete the first page.
  (To access password protected files, please contact SEI to obtain the requisite password.)
  
  
• New Adult Patients, please download and complete the following forms:
  

  Adult Intake Form (PDF file)

  Service Agreement Form (PDF file)

  DES II (PDF file)

  
  New Children and Adolescent Patients, please download and complete the following forms:
  

  Childhood History Form (PDF file)

  Service Agreement Form (PDF file)

  
  

Insurance Plans

If you plan to use Blue Cross/Blue Shield insurance, please Click Here.

If you plan to use United Behavioral Health insurance, please Click Here.

Other Checklists

• Edelbrock Rating Scale (PDF file)
• ADHD Symptom Checklist (PDF file)
• CDC (PDF file)
• A-DES (PDF file)
• Symptom Checklist (PDF file)
  

  Directions to Southeast Institute

  Collaborative Agreement (PDF file)

To access the forms provided on this page, you will need to be able to read Adobe PDF files. To do so, you will need Adobe Reader installed on your computer. If you do not have Adobe Reader, you can download it for free from Adobe by clicking on this icon: