Patient Forms

Once you schedule your appointment with Dr. Pelton, please electronically complete and submit the New Patient Evaluation form prior to your appointment. Please also print and sign the Contract/Consent form and bring it with you to the session.

New Patient Evaluation

I will work with you to develop a treatment plan that will meet your individual needs, provide insight, awareness, and ultimately symptom relief. This form is designed to help me understand your symptoms, goals, and mental health history. In order for me to be able to help you best, please complete each question as thoroughly and as honestly as possible. The form is secure, and can be safely submitted online.

Outpatient Services Contract/Consent

This agreement contains important information about my professional services and office policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPPA), a federal law that provides for privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. Please print and sign the form and bring it with you to the session.

Telebehavioral Health Consent

Telebehavioral health (TBH) is an electronic platform that allows for the delivery of psychological services using interactive audio or audiovisual electronic systems where the Psychologist and the patient are not in the same physical location. The interactive electronic systems used in TBH incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. Dr. Pelton uses VSEE, which is a secure and HIPAA compliant TBH system.


Please contact me if you have questions.

To venture causes anxiety, but not to venture is to lose one's self... 
And to venture in the highest is precisely to be conscious of one's self.
~ Soren Kierkegaard