| Mental Health Professionals |
Learn to Thrive not Simply Survive
A nonprofit corporation and independent licensee
of the Blue Cross and Blue Shield Association.
of the Blue Cross and Blue Shield Association.
We are proud members/participants of:
Forms
Welcome New and Existing Clients to our "Forms" page. Here you will find links and you as you
begin or are continuing on your journey of self-awareness, with Wentworth and Associates.
NOTE: Please allow enough time (approximately 30 minutes) to fill in the forms. Once you begin
filling in the forms, you must complete each one, in its entirety, as there is not an option that
allows you to "Save" and return at a later time.
Instructions:
Once you have clicked on the appropriate link in one of the two boxes below (Adult Packet or
Child/Adolescence Packet), you will be directed to a secure and encrypted site. Please fill in an
answer for each question on each form.
Forms to choose, after being directed to the secured site:
Form titles for Adults:
- Practice Orientation and Coordination of Care (same link for both Adults and Youth)
- Outcome Questionnaire Adult
- Life and Health History Questionnaire -- Insurance and Emergency Data
Form titles for Child/Adolescence:
- Practice Orientation and Coordination of Care (same link for both Adults and Youth)
- Outcome Questionnaire Youth
- Child and Adolescent Background Questionnaire
When all questions have been completed, please scroll to the end of the form and make sure you
click on "Submit" before exiting. Clicking "Submit" must be repeated for each of the three
forms. This step is critical to saving all the data, in which you just took your valuable time in
entering. Once you have clicked the "Submit" button, your data will go into a secured electronic
medical records file, which your therapist will be able to review and use throughout your ongoing
treatment, together.
Important: Please be sure to fill out all paperwork, prior to your first visit. This information will
help your therapist to understand you and save a great deal of time.
begin or are continuing on your journey of self-awareness, with Wentworth and Associates.
NOTE: Please allow enough time (approximately 30 minutes) to fill in the forms. Once you begin
filling in the forms, you must complete each one, in its entirety, as there is not an option that
allows you to "Save" and return at a later time.
Instructions:
Once you have clicked on the appropriate link in one of the two boxes below (Adult Packet or
Child/Adolescence Packet), you will be directed to a secure and encrypted site. Please fill in an
answer for each question on each form.
Forms to choose, after being directed to the secured site:
Form titles for Adults:
- Practice Orientation and Coordination of Care (same link for both Adults and Youth)
- Outcome Questionnaire Adult
- Life and Health History Questionnaire -- Insurance and Emergency Data
Form titles for Child/Adolescence:
- Practice Orientation and Coordination of Care (same link for both Adults and Youth)
- Outcome Questionnaire Youth
- Child and Adolescent Background Questionnaire
When all questions have been completed, please scroll to the end of the form and make sure you
click on "Submit" before exiting. Clicking "Submit" must be repeated for each of the three
forms. This step is critical to saving all the data, in which you just took your valuable time in
entering. Once you have clicked the "Submit" button, your data will go into a secured electronic
medical records file, which your therapist will be able to review and use throughout your ongoing
treatment, together.
Important: Please be sure to fill out all paperwork, prior to your first visit. This information will
help your therapist to understand you and save a great deal of time.
| Psychologists and Counselors serving the Tri-County Area, MI |
| Having trouble downloading the documents? To view these documents you will need a viewer called Adobe Acrobat Reader that can be obtained for free from: www.adobe.com |
Still having trouble viewing the documents?
Call our office at 586-997-3153 to have the forms
mailed directly to you.
Call our office at 586-997-3153 to have the forms
mailed directly to you.
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Printable Forms:
If you prefer to print the required forms for your visit,
please click on the appropriate link below and you
will be directed to a .pdf file, which you will be able
to download and print. Please make sure to bring
ALL forms with you to your first visit.
If you prefer to print the required forms for your visit,
please click on the appropriate link below and you
will be directed to a .pdf file, which you will be able
to download and print. Please make sure to bring
ALL forms with you to your first visit.
New Client Forms:
| All New Clients: Please click on link below. This form is for your review and W&A is required by HIPAA to provide. Privacy Practices Form |
W&A and HIPAA Required Form
NOTE: Internet Explorer 7 works best when viewing
and utilizing form packet links below. Also, please
disable your pop-up blocker prior to filling out forms.
and utilizing form packet links below. Also, please
disable your pop-up blocker prior to filling out forms.
| Client Satisfaction Survey Simply click on the link above then click "submit" when done. You may need to click "show links" and enable pop ups. |
Local Office: 586-997-3153
Toll Free: 877-321-WENT / Fax: 586-997-4956
Address: 11111 Hall Road - Suite 303
Utica, Michigan 48317 (West of Lakeside Mall)
(between Van Dyke and the Van Dyke Expressway)
Toll Free: 877-321-WENT / Fax: 586-997-4956
Address: 11111 Hall Road - Suite 303
Utica, Michigan 48317 (West of Lakeside Mall)
(between Van Dyke and the Van Dyke Expressway)