Patient Forms

After you have called to schedule an appointment with Dr. Kale Kirkland, you can visit this page, where there are a few forms for you to fill out.  After completing the forms, please do one of the following:
a) Scan and email to calapsych@gmail.com
b) Bring with you to our office at your first scheduled appointment

New Patient Forms

New Patient Form - Brief (Optional - Choose 1)
cap_new_patient_adult.doc
File Size: 88 kb
File Type: doc
Download File
New Patient Form - Comprehensive (Optional- Choose 1)
cap_1newpatientquestionnaire.docx
File Size: 47 kb
File Type: docx
Download File

Health Insurance Portability and Accountability Act

The HIPAA Privacy Rule provides federal protections for individually identifiable health information held by covered entities and their business associates and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of health information needed for patient care and other important purposes. 

The Security Rule specifies a series of administrative, physical, and technical safeguards for covered entities and their business associates to use to assure the confidentiality, integrity, and availability of electronic protected health information. 

Please Sign this form and return to submit to our office. (Required)
central_al_psychology_hippa.doc
File Size: 98 kb
File Type: doc
Download File

Informed Consent (Required)

Informed Consent - Adult

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cap_informed_consent_adult.docx
File Size: 43 kb
File Type: docx
Download File
Informed Consent - Child/Adolescent (Under 18)
informed_consent_for_treatment_-_adolescents_calapsych.docx
File Size: 29 kb
File Type: docx
Download File
Release of Information (Optional)
cap_release_authorization.docx
File Size: 39 kb
File Type: docx
Download File

APA Code of Ethics (2002)

apa_code_of_ethics.pdf
File Size: 228 kb
File Type: pdf
Download File
GOOD FAITH ESTIMATE STATEMENT - NO SURPRISES ACT 2022
calapsych_good_faith_estimate.docx
File Size: 40 kb
File Type: docx
Download File
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