Client Forms and Information
New Patient Forms
Appointment Inquiry (New Patients)
Fill out this introductory form so that I can reach out to you to schedule our first session.
Consent Form (New Patients)
Consent for treatment, communication practices, and financial policy.
Payment Method on File
Provide information regarding billing and payment for services.
Insurance Information
Provide information regarding insurance, if applicable.
Notice of Privacy Practices (HIPAA)
This notice describes how health information about you (as a patient of this practice) may be used and disclosed and how you can get access to your individually identifiable health information.
Release of Information
Complete one form for each provider that has past records. For instance, if you have been seen by multiple providers in multiple healthcare systems, record releases are needed for each system we are requesting records from.
Anxiety Screening Questionnaire
Complete as requested by provider.
Depression Screening Questionnaire
Complete as requested by provider.
ADHD Screening Questionnaire
Complete as requested by provider.
Rapid Mood Screening Questionnaire
Complete as requested by provider.
Questions? Reach out!
jansshealth@icloud.com
Phone: 515-858-7128
Fax: 515-993-9645
4123 University Ave
Des Moines, 50311