Pediatric | New Patient Forms

The following forms are required for new pediatric patients. 

Please print and complete prior to your appointment. 

 If your child will be seen for an ADD/ADHD evaluation the following additional forms are required. 

Please print and complete prior to your appointment.

Adult | New Patient Forms

 The following forms are required for all new adult patients. 

Please print and complete prior to your appointment. 

 If you are an adult patient that will be seen for depression, anxiety or bi-polar disorder the following forms are required. 

Please print and complete prior to your appointment.  

GTHC Sliding Fee Scale Program

 All private pay patients (new or existing) who are applying for the GTHC sliding fee scale program must complete and return the form below. 

If you are a new patient, you will need to submit the New Patient Packet (above) along with this form. 

Please bring the following items when you return your application:

 

  1. Last 30 days of pay stubs for yourself and spouse/partner; and/or
  2. Current front page of the 1040, 1040A or 1040EZ for yourself and spouse/partner; and/or
  3. Letters from employers stating average weekly or monthly income for yourself and spouse/partner; and/or
  4. Unemployment statements for yourself and spouse/partner; and/or
  5. Child support statement for yourself and spouse/partner; and/or
  6. A signed and dated letter from the person(s) supporting yourself and spouse/partner. The letter must include the dollar amount received weekly or monthly
  7. A recent utility bill for the address you have listed on the application, or
  8. Current driver’s license with the address on the applicationYour picture ID or driver’s license (if the patient is a child)
  9. Social Security Card for parents and children