Tarnow Center - Psychiatry, Psychology, Education, and Counseling

CONTACT US

CONTACT

Online Forms

Standard Forms

Authorization to Release Records (PDF)
Authorization to Release Family Member Records (PDF)
Consent to Treat (PDF)
Consent to Treat with Medications (PDF)
Credit Card on File (PDF)
Email Consent Form (PDF)
Mood Chart (PDF)
Monthly Billing Aggreement (PDF)
SNAPP Form (PDF)

Child and Adolescent Forms

Form for Lynn Ayres M.Ed (PDF)
Form for Paul J. Clear, Ph.D. (PDF)
Form for Yael R. Ebenstein Ph.D. (PDF)
Form for Elaine Frankel LMSW, ACP-PR (PDF)
Form for Sophia K. Havasy Ph.D. (PDF)
Form for Kimberly Kjome, M.D. (PDF)
Form for Linda Narun M.A., CCC-SLP (PDF)
Form for Diane N. Roche Ph.D. (PDF)
Form for Dr. Scott (PDF)
Form for Lesley Solomon M.A., LPC (PDF)
Form for Ron Swatzyna Ph.D., LCSW (PDF)
Form for Jay D. Tarnow M.D. (PDF)
Form for Lourdes M. Valdés Ph.D. (PDF)

Adult Forms

Form for Lynn Ayres M.Ed (PDF)
Form for Paul J. Clear, Ph.D. (PDF)
Form for Yael R. Ebenstein Ph.D. (PDF)
Form for Elaine Frankel LMSW, ACP-PR (PDF)
Form for Sophia K. Havasy Ph.D. (PDF)
Form for Kimberly Kjome, M.D. (PDF)
Form for Linda Narun M.A., CCC-SLP (PDF)
Form for Diane N. Roche Ph.D. (PDF)
Form for Dr. Scott (PDF)
Form for Lesley Solomon M.A., LPC (PDF)
Form for Debra Stokan M.D. (PDF)
Form for Ron Swatzyna Ph.D., LCSW (PDF)
Form for Jay D. Tarnow M.D. (PDF)
Form for Lourdes M. Valdés Ph.D. (PDF)

Legal Notice: The information on this website is intended only for broad general information and educational purposes only. It should not replace one-on-one therapy with a trained professional. We do not offer on-line psychotherapy and our email consultations should not be considered as therapy. ADHD Self-Management Center Online specifically disclaims liability, loss, or risk, personal or otherwise, that may be incurred as a consequence, directly or indirectly, in the use or application of any contents of this website.

If you are having severe psychiatric symptoms, please contact your closest mental health professional. If you are experiencing suicidal ideations, call your local hospital for immediate help.