Rodney E. Timbrook, Ph.D., HSPP 

Psychological Service Associates, Inc.

3421 E. State Blvd, Fort Wayne, Indiana

office telephone (260) 482-8427
office fax (260) 482-8429

Office Forms

I have included copies of forms that I use in my office for your convenience.  Please feel free to download, print, and complete before your first appointment.  You may download by right-clicking on any of the hyperlinks and selecting the "Save As" option.  

Those documents marked with an asterisk (*) are requested of all new patients.

*New Patient Form  (PDF Format)

*Services Agreement (PDF Format)

*Notice of Privacy Policies  (Word Format)  (PDF Format)

*Patient Health Questionnaire (PDF Format)

Release of Information  (Word Format)  (PDF Format)

Child Development History (Word Format) (PDF Format)

Child Characteristic Checklist (Word Format)  (PDF Format)

Parental Agreement (Word Format) (PDF Format)

Consent For Treatment of a Minor (Word Format)  (PDF Format)

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