600 Oakesdale Avenue SW #104 Renton, WA 98057: (425)-228-5336 | 5837 221st Place S.E. Issaquah, WA 98027: (425) 391-0887 |

All Other Locations: (206) 420-5416

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WA-Reception-RVP@LifeStance.com

THOM FIELD, PhD, NCC, LMHC

THOM FIELD, PhD, NCC, LMHC

Here are the forms and disclosure statement for you to be seen at River Valley.
Please complete the forms and print them out and bring them to your first appointment.

Forms Required for All Clients.
Billing Info Form
River Valley Benefit Verification Form
Privacy Notice Form
Additional Forms for Adults.
Informed Consent
Adult Checklist of Concerns
Adult Financial Policy
SCL-90-R – Available at Office
Additional Forms for Adolescents.
Informed Consent
Adolescent Informed Consent
Adolescent Checklist of Concerns
Financial Policy for Minors
SCL-90-R – Available at Office
Additional Forms for Children.
Child Informed Consent
Child Checklist of Concerns Pediatric Symptom Checklist
Financial Policy for Minors
Electronic Privacy Addendum