Patient Forms


 

HIPAA Notice

 

English

  1.  New Adult Patient (Ages 18-64) English
    1. Intake Packet New Patient – Adult
    2. Adult Intake – Screening Scales – English

  2.  New Geriatric Patient (Ages 65+) English
    1. Intake Packet New Patient – Geriatric
    2. Geriatric Intake – Screening Scales – English

  3. New Child Patient (Ages 5-12) English
    1. Intake Packet New Patient – C&A
    2. Child Intake – Parent Screening Scales – English
    3. Child Intake – Teacher Screening Scales

  4. New Adolescent Patient (Ages 13-17) English
    1. Intake Packet New Patient – C&A
    2. Adolescent Intake – Screening Scales – English

  5. Psychiatric Clearance – Bariatric Surgery (English)
    1. Intake Packet New Patient – Adult
    2. Intake Packet New Patient – Geriatric
    3. Bariatric Clearance - Screening Scales – English

  6. Psychiatric Clearance – Spinal Cord Stimulator (English)
    1. Intake Packet New Patient – Adult
    2. Intake Packet New Patient – Geriatric
    3. Spinal Cord Pain Management Clearance - Screening Scales – English

  7. Psychiatric Clearance – Gender Reassignment (Male to Female) (English)
    1. Intake Packet New Patient – Adult
    2. Gender Reassignment Clearance - Screening Scales - Male to Female – English

  8. Psychiatric Clearance – Gender Reassignment (Female to Male) (English)
    1. Intake Packet New Patient – Adult
    2. Gender Reassignment Clearance - Screening Scales - Female to Male – English
  9. Worker's Comp Intake Forms - English
    1. Intake Packet New Patient – Adult
    2. Workers Comp Intake - Screening Scales – English

 

 

Spanish

  1. New Adult Patient (Ages 18-64) Spanish
    1. Paquete Entrada Paciente Nuevo – Adulto
    2. Adult Intake – Screening Scales – Spanish

  2. New Geriatric Patient (Ages 65+) Spanish
    1. Paquete Entrada Paciente Nuevo – Geriatrico
    2. Geriatric Intake – Screening Scales – Spanish

  3. New Child Patient (Ages 5-12) Spanish
    1. Paquete Entrada Paciente Nuevo – C&A
    2. Child Intake – Parent Screening Scales – Spanish
    3. Child Intake – Teacher Screening Scales

  4. New Adolescent Patient (Ages 13-17) Spanish
    1. Paquete Entrada Paciente Nuevo – C&A
    2. Adolescent Intake – Screening Scales – Spanish

  5. Psychiatric Clearance – Bariatric Surgery (Spanish)
    1. Paquete Entrada Paciente Nuevo – Adulto
    2. Paquete Entrada Paciente Nuevo – Geriatrico
    3. Bariatric Clearance – Screening Scales – Spanish

  6. Psychiatric Clearance – Spinal Cord Stimulator (Spanish)
    1. Paquete Entrada Paciente Nuevo – Adulto
    2. Paquete Entrada Paciente Nuevo – Geriatrico
    3. Spinal Cord Pain Management Clearance - Screening Scales – Spanish

  7. Psychiatric Clearance – Gender Reassignment (Male to Female)
    1. Paquete Entrada Paciente Nuevo – Adulto
    2. Gender Reassignment Clearance - Screening Scales - Male to Female – Spanish

  8. Psychiatric Clearance – Gender Reassignment (Female to Male)
    1. Paquete Entrada Paciente Nuevo – Adulto
    2. Gender Reassignment Clearance - Screening Scales - Female to Male - Spanish
  9. Worker's Comp Intake Forms - Spanish
    1. Paquete Entrada Paciente Nuevo – Adulto
    2. Workers Comp Intake - Screening Scales – Spanish
What we offer

Services

Location
Lumos Psychiatric Services
6001 Vineland Road, Suite 109
Orlando, FL 32819
Phone: 407-287-5618
Office Hours

Get in touch

407-287-5618