2026 UPD New Patient Registration Form

This form will provide information about our services and about your rights and responsibilities as a client. Please be sure to discuss any questions with your clinician or our front staff. Your signature or initial at the bottom of each page indicates that you understand the information and agree to each section.

 THIS INTAKE PACKET, INCLUDING ALL CONSENTS AND POLICY ACKNOWLEDGMENTS, MUST BE COMPLETED AND SIGNED BY THE APPROPRIATE INDIVIDUAL, AS OUTLINED BELOW: 

• Patients 18 years of age or older: The patient must personally complete and sign all forms, unless they are legally unable to do so. 

• Patients under 18 years of age: A parent or legal guardian must complete and sign all forms on the patient’s behalf. Once the patient turns 18, the legal guardian will not be able to consent on the behalf of the patient, unless documentation is provided. 

• Patients 18 years of age or older who are unable to consent or complete forms independently (including due to cognitive, developmental, medical, or physical limitations): A legally authorized representative, such as a legal guardian or conservator, must complete and sign all forms on the patient’s behalf. 

 BY SIGNING THIS PACKET, THE UNDERSIGNED CONFIRMS THAT THEY ARE LEGALLY AUTHORIZED TO COMPLETE THESE DOCUMENTS AND PROVIDE CONSENT WHERE REQUIRED. THE CLINIC RESERVES THE RIGHT TO REQUEST DOCUMENTATION VERIFYING LEGAL AUTHORITY (SUCH AS GUARDIANSHIP ORCONSERVATORSHIP PAPERS) AT ANY TIME.

IF NOT SELF: PLEASE COMPLETE THE FOLLOWING:

I confirm that I am the patient’s legal guardian or authorized representative and can provide consent and acknowledgepractice policies on their behalf. I agree to notify Progeny Psychiatric Clinic if this authority changes and understand that Iam responsible for adhering to practice policies.