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. The document marked with two asterisk (**) are requested only of patients receiving telehealth services. 

*New Patient Form  (PDF Format)

*Services Agreement (PDF Format)

*Notice of Privacy Policies    (PDF Format)

**Telehealth Informed Consent (PDF Format)  

 Patient Health Questionnaire (PDF Format)

Release of Information     (PDF Format)

Child Development History  ( PDF Format)

Child Characteristic Checklist  (PDF Format)

Parental Agreement (PDF Format)

Consent For Treatment of a Minor   (PDF Format)

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