Request an Appointment
Please do not use this form if you have an urgent problem or you need to reschedule an existing appointment. Instead, contact our office at (770) 815-6853. After you submit your request, our appointment scheduler will respond within 48 hours. See below for forms to complete. Established patients may log in to the patient portal to request appointments and update forms.
Patient Registration Forms
Atlanta Specialized Care in Atlanta, Georgia welcomes you to our practice. Once you have made your initial appointment, you may preregister by downloading, printing, and completing the forms below. Doing so prior to your visit will help speed up the new patient registration process.
Downloadable Forms
- Admitting Form
- Self-Report – Adult
- Self-Report – Child and Adolescent
- Consent to Release or Receive Information
- Patient Health Questionnaire
- Atlanta Specialized Care Telemedicine Informed Consent
- Coordination of Care Form
- ASC 2024 Medicare-Opt-Out-Affidavit
- Disclosure for Kathryn Butler, FNP-BC
- Disclosure for Tatiana Matthews, MS, LPC, CRC
- Disclosure for Erin Mills, MSW, LCSW
- Disclosure for Neitcha Thomsen, LMSW, LCSW
- Disclosure for Theresa Westfall, MS, LPC, NCC
- Disclosure for Bre Curtin, MS, NCC, APC
- Disclosure for Ross Mills, MS, APC
- Disclosure for Natalie Stadnick-Uhl, M.Div, LPC, CRC
- Disclosure for Jessica Fosse, MS, CRC
- Disclosure for Delaney Banzof, BS, Masters Level Student Intern
Please note: It may take a few minutes to load the forms if you are using a slow internet connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the icon below.
