Please print out and fill out the forms
and bring them to your appointment
Forms filled out on-line do not get saved.
If you're a new client or a caregiver establishing individual care, please complete the following forms and bring them to your first evaluation session.
If you are a person LIVING with dementia please fill out The Initial Evaluation Form and please ask your family care partner to complete caregiver forms and bring them to your first evaluation session
- Disclosure to friends and family Form
- ReCode Questionnaire
- Authorization to Disclose Information to Helath Care Professional Form
- Medical History, Care Coordination form
- Symptom monitoring form (ALL)
- Symptom Monitoring form for a person with moderate to severe dementia
- Medications Monitoring form
- Sleep Monitoring form
- Drinking Monitoring form
- Exercise, Food Monitoring form
- Consent for Neurofeedback form
- Apapthy Evaluation Scale
- Spiritual Health Assessment
- Controlled Substances Agreement Form
- Care Partner Stress form
- Dementia Care Partner (Patient Symptom Monitoring )
- Relationship Wants Worksheet
- Self-Care Worksheet
- Relationship Fears Worksheet
Note: To download Adobe Acrobat Reader for free , click here .
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.
- Suspected child abuse or dependant adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
- If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
- If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.
- If you are experiencing a medical emergency please call 911 or go to the nearest emergency clinic. Please leave me a message with an update. Please share my phone number with hospital clinicians and request that they contact me for care coordination.
- If you are experiencing a psychiatric emergency you can call or email me, but please be aware that I may not be able to get back to you for several hours. If you need urgent help, please call 911, or go to the nearest emergency clinic. Please leave me a message with an update. Please share my phone number with hospital clinicians and request that they contact me for care coordination.
Call 911 for emergencies and to have the patient transported to a local emergency room.
Geriatric Regional Assessment Crisis Team
Geriatric Crisis Service is a specialized crisis intervention and stabilization service available to older adults in King County.This service is provided by the Geriatric Regional Assessment Team, which consists of geriatric mental health specialists, chemical dependency professionals, social workers, a nurse, an on-call occupational therapist and a psychiatrist. The team works collaboratively to provide in-home mental, substance abuse, medical, psychosocial and functional assessments for people age 60 and older who meet the criteria for eligibility. There is no fee for these crisis services, thanks to funding from the King County Mental Health and Chemical Dependency Department. The Geriatric Regional Assessment Team will see individuals within three business days of referral.For questions on eligibility or to make a referral, call: 425.899.6300 or 1.800.548.0558 (toll free)
Volunteers of America Care Crisis Response Services: Provides a 24-hour line with crisis intervention counseling, suicide intervention, and access to mental health emergency services for Snohomish, Skagit, San Juan, Island, and Whatcom Counties. Emergency Services are available regardless of patient’s funding.
(425) 258-4357 or (800) 584-3578 www.voaww.org
Volunteers of America Triage Line: A physician resource for use in accessing emergency outreach or next-day appointments for patients. Staffed with mental health professionals who assess the needs of the patient and refer them to the proper treatment center. Emergency services are available regardless of patient’s funding.
North Sound 2-1-1: Directs patients to the most appropriate health and human services resource, specialized information, or referral line in your community. The call center is staffed weekdays from 8:00am-5:00pm. After-hours messages returned the next business day. Call 2-1-1 if you live in Island, San Juan, Skagit, Snohomish, or Whatcom County
County Designated Mental Health Professionals: The Involuntary Treatment Program serves the mentally ill or chemically dependent and those who may be dangerous to themselves, others, or property, or those requiring evaluation for involuntary commitment. Designated Crisis Responders (DCR’s) evaluate individuals with alleged mental illness or debilitating chemical dependency. The DCR will determine if legal criteria are met for commitment.
(425) 388-7215 —during business hours
(800) 747-8654—24/7 through the VOA Triage Line
LOCAL HOSPITALS click here
- All new medications will be started only during an appointment
- All medication doses will be adjusted only during an appointment
- No early refills for controlled substances : stimulants and benzodiazepines
- All medication refills are given during an appointment
- If you forget to ask for a refill, please contact your pharmacy and ask for a refill request to be faxed to: 1(888)-296-8140
- Please allow 3-4 business days for a refill
- A fee for a medication refill outside of scheduled appointment may be assessed