Forms and Prescription Refill Request
Please Note:
Policy: We require 72 hours advance notice to call in prescriptions with no refills remaining and for writing scripts for controlled substances. If you have refills, please contact your pharmacy to request a refill.
To request a refill for your prescription please complete the form, or call (319) 626-3300 and select Option 1.
We will make every effort to accommodate emergencies.
Please note: If you have missed appointments or not been seen as recommended by your clinician, we may ask you to schedule an appointment at the time of refilling your prescription in order to provide safe and effective care, and to be in compliance with Federal and State prescribing guidelines.
Printable Forms
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Click hereto open and download the full packet of information.
You may complete this form online by clicking here. -
Below are the individual pages that can be found in the New Patient Information Complete Packet.
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Click Here to open and download the HIPPA Notification of Privacy Practices.
Click Here to open and download the HIPPA Receipt Confirmation Form
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Click Hereto open and download the Authorization to Request Protected Information in printable PDF Form.
Ciick Here to complete this form online. -
Click Hereto open and download the Authorization to Request Protected Information in printable PDF Form.
Ciick Here to complete this form online. -
Click Here to complete the Child Patient Intake Form online.
Click hereto download a printable version. -
Click Hereto complete the School Report Form online.
Click Here to download the printable version -
Click Here to complete the Adult Patient Intake Form online.
Click Hereto download the printable version -
Click here to download the Psychology Service Agreement