Forms | dbpcaa

Downloadable Forms

Getting Started

For the initial evaluation, please download and complete the following forms:

Credit Card Authorization Form

Psychological Services and Policies

Biopsychosocial History

Please download and complete the Consent to Assume Responsibility for Payment Form if you are going to be paying for the services received by your adult child (i.e., college student).

Consent to Assume Responibility for Payment Form

Optional Forms

Please download and complete the Release of Information Form if you would like Dr. Benavidez to speak with or provide information to another provider (i.e., psychiatrist, primary care physician, school counselor, etc.).

Dominique Benavidez Ph. D.

Downloadable Forms

Adult Intake Form

Child Intake Form

Credit Card Authorization Form

HIPPA Privacy Notice Form

Psychological Services and Policies

Biopsychosocial History

Consent to Assume Responibility for Payment Form

Release of Information Form