Phone: 612-766-9255 Email: kmh@kevinharringtonphd.com

Psychotherapy Forms

If you are interested in psychotherapy, I would appreciate you contacting me at 612-766-9255. After we have agreed to make an appointment, please print (on one side of the paper), read and complete the following forms. Please mail the originals and a copy of your insurance card into my office. If you're going to use insurance, please contact your insurance company to determine your coverage. Thank you.

Adult Forms

All Adult Forms
Adult Registration Form
Outpatient Services Contract
Adult Intake Questionaire
Data Privacy Form

Child Forms

All Child Forms
Child Registration Form
Outpatient Services Contract
Pediatric Psych New Patient Info
Consent for Treatment of a Minor (ages 5-12)
Data Privacy Form

Teen Forms

All Teen Forms
Child Registration Form
Outpatient Services Contract
Pediatric Psych New Patient Info
Consent for Treatment of a Minor (ages 13-18)
Data Privacy Form

Optional Forms

Credit Card Pre-Authorization Form
Private Information Release Form
Integrating Mind, Body, and Heart