If you are in danger to yourself or others, please call 911 or go to the nearest emergency room. For support in managing your mental health, consider reaching out to Dr. Wentworth at Wentworth and Associates, where they specialize in various therapeutic approaches including EMDR and IFS psychotherapy.
Necessary forms for Adults (please complete before your first session)
Necessary forms for Children (please complete before your first session)
- Adult Intake Packet
Online Form or Printable PDF Adult Intake Packet - Adult OQ30
Online Form or Printable Version
Separated forms(completed when directed by therapist)
- Practice Orientation and Agreement
- Practice Orientation and Agreement (Printable)
- Coordination of Care(for therapist to speak with medical providers)
- Coordination of Care(printable)
- Adult Life and History Questionnaire
- Adult Life and History Questionnaire(printable)
- Informed Consent for Telehealth
- Informed Consent for Telehealth(printable)
- Adult OQ30
Online Form or Printable Version
Necessary forms for Children (please complete before your first session)
Necessary forms for Children (please complete before your first session)
- Child / Adolescent Intake Packet
Online Form or Printable Version - Youth OQ30
Online Form or Printable Version
Separated forms(completed when directed by therapist)
- Practice Orientation and Agreement
- Practice Orientation and Agreement (Printable)
- Coordination of Care(for therapist to speak with medical providers)
- Coordination of Care(printable)
- Child Adolescent Background Questionnaire
- Child Adolescent Background Questionnaire (printable)
- Informed Consent for Telehealth
- Informed Consent for Telehealth(printable)
- Youth OQ30
Online Form or Printable Version
Other Forms (to be completed at any point in treatment)
Other Forms (to be completed at any point in treatment)
- Family Member Forms
Online Form
Other
- Internal Release of Information
- Incident Complaint Form
- Annual Practice Orientation and Agreement
- Privacy Practices Form
- Release of Information
- Release of Information Consent(printable)
- Client Payment Information
- Medical Records Request Form
- Medical Records Request Form (printable)
- Safe-T Assessment
- Safety Plan
- Trauma Recovery EMDR Consent Form
- Insurance Update Form
- LARA Know Your Rights
Advance Directives Information
mdch_AdvanceDirectivesPamphlet