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Patient Forms

Patient Forms

Professional Psychiatry Tailored to Your Unique Mental Health Needs

New Patients

Download Full Packet (PDF)

Credit card Collection
Receiving Health Information-Diligence
Controlled Substance Agreement
Fee Agreement as of 8-21-2023
HIPAA and Privacy Notice
Office Policies and General Information
Patient-Provider Policy Agreement
Personal Representative Request-MedTrainer-Diligence
Psychiatrist-Patient Policy Agreement
SMS and Phone Consent
Standard Psych Form Intake ZD
Treatment Consent Form

Existing Patients

Download Full Packet (PDF)

Credit card Collection
Receiving Health Information-Diligence
Authorization for Disclosure of Protected Health Information-MedTrainer-Diligence-Sending out
Patient-Election-to-Self-Pay
Revocation-of-Patient-Election-to-Self-Pay

Please follow the instructions below after downloading your forms:

  • 1. Download the full packet above or select only the forms you need.
  • 2. All forms are fillable directly in your browser or PDF editor.
  • 3. Once complete, save the forms and email them to: info@diligenceintegratedcare.com

If you have any questions, please contact our office for assistance.

You deserve to be happy simply because you are human. Your past experiences, mistakes, or challenges do not diminish your right to joy and fulfillment. Happiness is not a reward to be earned but a state of being that everyone is entitled to. Embracing this truth can be a powerful step toward healing and self-acceptance.
New Patients

(909) 276-1198

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