QBH Forms

New Patient Forms:

Patient Interview Sheet
Rules of Practice
Patient Informed Consent for Treatment
HIPAA Notice of Privacy Practices
HIPAA Signature Form
Patient Past Medical History Form
Current Care Form
QuitWorks Form

Returning Patient Forms:

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure -Child 11-17
DSM-5 Parent/Gaurdian-Rated Level 1 Cross-Cutting Symptom Measure -Child 6-17
DCYF Packet
Dr. Audet Teacher Questionnaire
Dr. Audet Developmental and Behavioral Pediatrics Intake Questionnaire
Dr. Audet Developmental and Behavioral Pediatrics Intake Form

Patient Assistance Applications:

Astrazeneca Patient Assitance (Seroquel)
Bristol Myers Patient Assistance Form ( Abilify)
Cymbalta Patient Assistance
Forest Pharmaceuticals (Celexa,Lxapro,Viibryd)
Glaxo Smith Kline Bridges to Access (Lamictal)
Johnson & Johnson Patient Assitance Form( Invega, Risperdal)
Pfizer Connection to Care Patient Assistance Program
RX Outreach Application (Paxil, prozac, ativan, ambien, buspar, tegretol, levothyroxine, inderal, depakote,neurontin, xanax, wellbutrin, celexa)
RX Outreach Program List of Medications
Saphris Patient Assistance Form
Shire Patient Assitance (Intuniv,Carbamazepine,Vyvanse)
Sunovion_Support_Application