Alabama Psychiatric Services (APS) makes the following forms available for our patients’ use:

 
Authorization to Release Protected Health Information (QA 25-A) – This document must be completed by any patient requesting APS to disclose information regarding their treatment to any other source outside APS.  Usually, this document is signed with a clinician in any APS office.  However, we recognize there are times when it may not be convenient for a patient to come to our office for this purpose.  The Authorization can be printed and signed outside an APS office, but when doing so, the patient must have this document notarized and send the original to APS.  Any patient wishing to have their Protected Health Information disclosed to another source should first discuss it with the clinician providing their treatment.

Authorization to Request Protected Health Information (QA 25-B) – This document must be completed by any patient who wants APS to obtain their Protected Health Information from another medical professional.  During the course of treatment, it is often helpful for APS to obtain medical information from another healthcare provider.  This is particularly true when a patient has seen another mental health provider in the past.  Patients can complete this document in any APS office or can print it from the website and provide it to their healthcare provider whom they would like to share information with APS.

Child/Adolescent Parent Questionnaire (QA 7CA pages 1-4) – APS believes that a parents’ input is vitally important in assessing a child or adolescent.  In order to obtain this parent input, APS has developed a Parent Questionnaire.  This document can be printed from the website and completed by parents who’ve made an appointment for their child.  The completed questionnaire should be brought to the initial appointment.  This saves time for the parent and gives you an opportunity to complete the questionnaire in your own environment, allowing you time to carefully consider your responses. 

Child/Adolescent Symptom Assessment & Outcome Measurement – Teacher Form (QA-CA 35b) – APS is committed to the measurement of patient outcomes.  We believe that a teachers’ input often is very important in assessing a child or adolescent.  In order to obtain this teacher input, APS has developed a Child/Adolescent Symptom Assessment Form for teachers to complete.  This instrument allows teachers who spend significant time with the patient, to answer questions regarding their observations of a patient’s symptoms that may be observed in the classroom setting.  Parents are encouraged to print this form and give to their child’s teacher(s), have them complete it and return it to the parent. The parent should then bring the completed forms to the initial appointment. 

Adult Patient Questionnaire (QA 42) – Patients entering treatment at APS may be evaluated by a psychiatrist, psychologist, or master’s level therapist.  Those adult patients seeing a therapist are asked to complete this questionnaire prior to their first appointment.  The questionnaire can be printed from our website, and completed by the patient and brought to the initial appointment.