Document Upload Form Patient's Name:(Required) First Last Patient's Date of Birth:(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the patient a minor or have other legal guardianship?(Required) Yes No Responsible Party/Legal Guardian:(Required) First Last Email:(Required) Primary Phone:(Required)Other Phone:Please provide a description of each file that you are uploading:(Required)File Upload:(Required) Drop files here or Select files Accepted file types: pdf, doc, jpg, png, Max. file size: 128 MB. Does your treatment provider need to be notified that you have uploaded recent documents?(Required) Yes No Please Check All That Apply:(Required) Christopher Bojrab, MD Andrew Brothers, PhD Deborah Bykowski, PMHNP-BC Deborah Carpenter, PMHCNS-BC Katherine (Katie) Clendenen, LMHC Beili Dong, MD Jenna Doyle, LMHC Christina Falink, LCSW Corey Falink, LMHC Tyler Flaningham, MD Jessica Fogle, LCSW Elizabeth Goebel, LMHC Marcy Haboush, LCSW Kirsten Hammersley, PMHNP-BC Marabeth Holland, LMHC Beverly Inman-Dunigan, LCSW Elizabeth Irick, LMHC Shiela Irick, MD Jennifer Jansen, LCSW Robert Jeffries, PhD Rich Jones, PhD Nancy Jungemann, PMHNP-BC Kim Keller, LMHC Stephany Keys, PsyD, HSPP Seth Kleiman, LMHC Kourtney Klepfer, LCSW Maryann Lake, LCSW Bethany Littrell, LMHC Jennifer Martynowicz, MD Mary McAteer, MD Christine Miller, DO Scott Minnich, MSW, LSW Sanjay Mishra, MD Laurie Moyer, LCSW, ATR Jennifer Myers, LCSW Shaunna Norris, LCSW Jill Oliver, PMHCNS-BC Terry Parrish, MD Tina Ramseur, LMHC Jane Rapinchuck MD Danielle Reeves, LMFT Michelle Rinzel, LCSW Mary Roth, LCSW Carrie Schaefer, LCSW Camille Sexton-Villalta, PhD Dan Shelpler, PMHNP-BC Jenn Stepic-Wenzel, LMHC Calvin Thornton, PMHNP-BC Michael Webber, MD Steve Wilson, PMHCNS-BC Polly Westcott, PsyD Other/Not Listed Please provide any additional information (if any) that would be helpful pertaining to document(s) you have uploaded.Consent(Required) I agree to the statement below.(Required)I understand that the attached documents will be uploaded into the medical record of the patient listed above.
