Southeast Institute

Intake Forms for

Dr. Peterson's Clinical Practice

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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 (PDF file)

Service Agreement (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)

Other Checklists

Edelbrock Rating Scale (PDF file)
ADHD Symptom Checklist (PDF file)
CDC (PDF file)
A-DES (PDF file)
Symptom Checklist (PDF file)
Release of Information (PDF file)
Directions to Southeast Institute
Collaborative Agreement (PDF file)
Consultation Agreement (PDF file)


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