Patient Policies

To access our Patient Policies document (including Privacy Policy) click here.

PATIENT POLICY & GUIDELINES FORM, click here


New Patient Packet

To access the New Patient Packet, click on the link below. The packet will open. Please fill out and hit submit


Child Registration Packet

To access the Child Registration Packet, click on the link below. The packet will open. Please fill out and hit submit.


Authorization To Obtain Medical Information

This specific form authorizes us to obtain your records from your previous provider. For example, if you are new to Atkinson Family Practice, fill this form out and we can obtain your records from your old practice.  To access the Authorization for Release of Medical Information form, click on the link below.


Authorization for Disclosure of Medical Information

This specific form authorizes us to send your records to another practice. For example, if you are moving and need us to send your records to a new practice, or are seeing a specialized doctor and they need to see your medical history, fill out the information of where you want the records to be sent.  Please note: there is a fee to disclose records to yourself.  We ask for 30 days notice to send medical records.


Health Care Proxy Form

To fill out the Health Care Proxy Form, click on the link and a form will open. Please fill out the form online and hit submit.

Patient Health Questionnaire

To fill out the Patient Health Questionnaire, click on the link and a form will open. Please fill out the form online and hit submit.

Financial Responsibility Form

To fill out the Financial Responsbility Form, click on the link and a form will open. Please fill out the form online and hit submit.

HIPAA (Fill Out Yearly)

To fill out the HIPAA Form, click on the link and a form will open. Please fill out the form and hit submit.

Pediatric Symptom Checklist

To fill out the Pediatric Symptom Checklist, click on the link and a form will open. Please fill out the form and hit submit.

Child's ADHD Follow Up Form

To fill out the Child's ADHD Follow Up Form, click on the link and a form will open. Please fill out the form and hit submit.

Adult ADHD Form

To fill out the Adult ADHD Form, click on the link and a form will open. Please fill out the form and hit submit.

IIEF 5

To fill out the IIEF5, click on the link and a form will open. Please fill out the form and hit submit.

IIEF15

To fill out the IIEF15 click on the link and a form will open. Please fill out the form and hit submit.

Adult Sleep Questionnaire

To fill out the Sleep Consult packet, click on the link and a form will open that you can fill out online and submit.

Child Sleep Questionnaire

To fill out the Child Sleep Questionnaire, click on the link and a form will open. Please fill out the form and hit submit.

TMS Forms

 Please email here if you have any questions about the forms below.



Please fill out either of the forms below to see if you are qualified for treatment