Intake Forms

Click below to download the appropriate form. Have a question about which forms you need to complete? Please contact us.

Authorization & Consent Forms

Authorization PHI
Consent PHI
Informed Consent
Telehealth Informed Consent
Notice of Privacy Practices

Background Forms (Adults)

Background Info (Adults)

Background Forms (Child / Adolescent)

Background Info (Children)
Child Adolescent Feedback - Parent
Child Developmental History

COVID Forms

COVID Precautionary
Release
COVID Informed
Consent
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Hugh S. Smith, Ph.D. & Associates, P.C.
Main Office: 1831 Lititz Pike
Lancaster, PA 17601

Phone: (717) 391-6808
Fax: (717) 391-0709
E-mail: HSSA@hssmithassociates.com 

 ©  2021  Hugh S. Smith, Ph.D. & Associates, P.C. All Rights Reserved.