Dr Martin Johnson:

808-538-7793

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Patient Forms

If you are a new patient, please complete the appropriate forms below and bring the completed forms with you to your first visit. 

Click on the title of the document you need to access the form.

For New Therapy Patients Only: Please bring completed form(s), ID, and insurance card(s) to your first appointment. Thank you for your cooperation.

Facesheet: Please fill this form out and bring with you to your first appointment.

Therapy Services Agreement: Your doctor will review this agreement with you during your first session; however, please be sure to look through it. Any questions can be discussed during your first appointment.

Notice of Privacy: This notice is for your records and does not need to be brought in; however, please be sure to look through it. Any questions can be discussed during your first appointment.

If applicable, please also fill out and bring your Minor Consent Form: Each legal guardian of a minor (younger than 18 years old) patient is required to complete this form in order for their child to be seen.

For Assessment Patients Only: If you are coming for psychological testing, please bring completed form(s), ID, and insurance card(s) to your first appointment. Thank you for your cooperation.

Assessment Services Agreement: Your doctor will review this agreement with you during your first session; however, please be sure to look through it. Any questions can be discussed during your first appointment.

Notice of Privacy: This notice is for your records and does not need to be brought in; however, please be sure to look through it.

Adult History Form: If you would like to complete the form before coming in to streamline the check-in process, please feel free. If not, please allow ample time to complete paperwork in house.

Child History Form: If you would like to complete the form before coming in to streamline the check-in process, please feel free. If not, please allow ample time to complete paperwork in house.

Minor Consent Form: Each legal guardian of a minor (younger than 18 years old) patient is required to complete this form in order for their child to be seen.

For All Patients:

Notice of Privacy: This notice is for your records and does not need to be brought in; however, please be sure to look through it. Any questions can be discussed during your first appointment.

Authorization to Release: Filling out an authorization is recommended if you have someone that you would like to assist you in billing, scheduling or being able to speak with your doctor. When filling out an authorization:

1. Please be sure to check off “to release” AND “to obtain” at the top of the form.
2. Please write the patient’s name and birth date (MM/DD/YEAR).
3. Please understand that only one person’s name or organization is allowed per authorization form. (for example, authorization to release to: ABC Company; or to: John Smith, M.D.)
4. Please check off the box to mark the purpose of the authorization, and please be sure to put your initials on the line next to the selected box.
5. Authorizations expire a year after the date signed; however, you do have the option to denote another date for expiration.
6. Please do not forget the patient’s name in print, patient’s signature and date.
 

Minor Consent Form: Each legal guardian of a minor (younger than 18 years old) patient is required to complete this form in order for their child to be seen.

Patient Document Request Form: This form allows patients to request documents, such as detailed receipts for flex plans. Please fill this form out accurately and completely to the best of your ability. Please also be aware that we will need approximately two weeks to process all requested documents. We will work to get it out sooner if possible.

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We look forward to hearing from you.