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Chesapeake bay psychological services llc

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Our Staff
Our Services
Schedule Online
Make a Payment
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Forms
Contact Us

Forms

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Required Forms

New Client Paperwork--The CBPS New Client Packet is required for all new clients. It provides information regarding our services and rates, as well as directions to the office. After completing, printing, and signing, e-mail the form to admin@chesapeakebaypsychological.com, fax it to 877-643-0126, or bring  it to your first appointment.

Optional Forms

 Adult Screening Form.pdf--For adults, the client may print and complete the Adult Screening Form and bring it to the first appointment.

 Child Screening Form.pdf and Child Background Form.pdf--For children aged 6 to 17, parents may print and complete these forms and bring them to the first appointment.

  Dr. Thorpe's Developmental Questionnaire- Especially for Dr. Thorpe's clients, parents may print and complete this form and bring with them to the first appointment.

Other Forms

 Authorization to Release Information.pdf--To authorize the release of information to or from CBPS, a client or guardian may complete, print, sign, and return this form.

 CBPS Credit Card Agreement.pdf--To authorize CBPS to charge a credit card each time a balance is due on the account, the cardholder may complete, print, sign, and return this form.

 CBPS Guarantor Fee Agreement.pdf--If someone who did not sign the original Fee Agreement wishes to take responsibility for payment, that person may complete, print, sign, and return this form.

 CBPS Discount Application for Families.pdf--For clients or families unable to pay our customary fees, an adult family member may use this form to apply for a discount based upon income and family size. (Approved discounts are applied to future services only.)

 

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