Outpatient Forms

Welcome to Crossroad Counseling and Consulting Associates, PC, your Psychiatry, Mental Health and breakthrough TMS Treatment provider!

Our new patient registration forms and consent forms are available for download on this page or in our office when you arrive for your first appointment. We kindly ask you to complete these forms before your visit. Please bring the completed forms, your insurance card, government issued identification, and your payment to your first visit. If you chose to complete form in the office before you first appointment please arrive 20 minutes prior to your appointment time.
New patient packet is your way to introduce yourself to our practice and it provide valuable information to our administrative and clinical staff. Each of the questions will help our physicians and clinicians in assessment of your problems. If you would like to receive a copy of the forms please notify the receptionist.

Software you’ll need

To view and print our office forms you’ll need the freely available Adobe Reader software installed on your computer. It is recommended to upgrade to current version of Adobe Reader.

Adobe Reader XI can be downloaded is here: http://get.adobe.com/reader

Your web browser may be configured with an Adobe Reader plug-in to automatically open the file within your browser’s window when accessed. We recommends that you save the PDF file to your computer and access the file locally. This allows the full Adobe Reader application to interface with the form. To download the file directly to your local drive, use right click of the mouse on the button then select “Save Target/Save Link As…” from the menu. Use Adobe Reader to open the file.


Printing the forms

Open the form using Adobe Acrobat Reader or Adobe Acrobat. Go to “Print” either in the “file” menu or by selecting the print icon. Once the print dialogue box is open, select the “fit to page” option. This ensures that the page that you see on the screen will correspond to the page printed by your printer. Once forms are printed please complete with dark pen, date, sing and bring to the office at the time of your visit.


Downloading the forms

You can download all forms below (number 1 thru 10).

Name of the FormClick to download
1New Patient Registration FormDownload Now
2New Patient Confidential Intake FormDownload Now
3Notice Of Privacy PracticesDownload Now
4Acknowledgement of Receipt of PP noticeDownload Now
5Signature on FileDownload Now
6Statement of Client Rights & ResponsibilitiesDownload Now
7Therapy Treatment Agreement Children and AdultsDownload Now
8Prescription Medication InformationDownload Now
9Email Correspondence ConsentDownload Now
10Service Agreement & Consent to TreatmentDownload Now

Patient Disclaimer & Privacy Notice

CCCA, PC website is designed to help our visitors and patients learn about our services and our practice, mental health and psychiatry. Information on CCCA, PC website is not intended to provide any specific medical advice and we urge you to consult with a qualified mental health or health care provider for diagnosis and for answers to your personal questions. If you feel any of the information regarding mental heal disorders may apply to you please contact out office for appointment.

State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with Patient Privacy Notice.
This Notice outlines typical uses and disclosures of health information; your privacy rights as our patient and how to contact us regarding any questions or complaints you may have. You may request a paper copy of our Privacy Notice at any time by contacting our Privacy Officer. Dr. Jasbir Kang. You may review and print Patient Privacy Notice on our website under section Patient Portal.


Check if your medication manufacturer has PATIENT ASSISTANCE PROGRAM and if you qualify for it. A patient assistance program provides prescription medicines to patients in need who do not have prescription drug coverage or who are underinsured through either private and/or government health plans. Each pharmaceutical company determines the eligibility criteria for its patient assistance programs. Almost all PAP’s require proof of income; application can be completed by patient or patient advocate. Please visit Patient Portal section to learn how to apply.