[Skip to Content]

Forms

 

If you would like to refer a client, you may use the Referral Form and fax it to 575-541-3645.

If you would like PBCG to share information about your treatment or condition, or if you would like another provider to share information about your treatment or condition with PBCG, you may use this form to authorize the release of the information you choose.

Authorization to Disclose Protected Health Information- HIPAA Release

 

INTAKE FORMS

  • Any and all forms must be sent to [email protected]
  • New clients must return any and all intake forms prior to their scheduled appointment.
  • Please be sure to bring all of your completed forms to your initial visit
  • Completing your new client forms prior to your initial appointment will save you the time required to complete these forms in the waiting room.
  • Please click the links below to print the appropriate forms. Each client will download 2 files. Select between forms for adult clients and minor clients. Please bring these forms on your initial visit.
  • A PDF program, such as Adobe Acrobat Reader, is required to view, edit, and save the fillable forms provided. If you do not already have Adobe Acrobat Reader installed, please click the following link to be taken to the download page: Adobe Acrobat Reader DC Free Download
  • Save the PDF file before editing, and then check the PDF file after you have edited and saved it to ensure the information you filled out is still there.

 

Crisis

Crisis Intake Packet Adult-Minor

2nd Appt Packet

Payment Policy Informed Consent (For Minors Only)

Español - Paquete de Admisión para Crisis, Adultos y Menores

Español - Paquete para la 2da Cita

 

Adult Forms (18 years old and older)

Explanation of Services and Privacy Practices

Adult Intake Packet

Español - Paquete de Admisión para Adultos

 

Minor Clients (younger than 18 years old)

Explanation of Services and Privacy Practices

Minor Intake Packet

Español - Consentimiento Informado para Servicios de Terapia en Línea

Español - Paquete de Admisión para Menores

 

Assessments

For PTSD: Abbreviated PCL-CLPC-C Abreviado 

For PTSD: PCL-5PCL-5 en Español 

For anxiety: GAD-7GAD-7 en Español 

For depression: PHQ-9PHQ-9 en Español 

For suicidal thoughts: CSSRSCSSRS en Español

 

InSync

If you have already registered, click here to visit the InSync patient portal.