David Penner MD PLLC

Child, Adolescent and Adult Psychiatrist
324 West Bay Dr NW #214, Olympia WA 98502
Phone:  360 539-1736  Fax:  360-350-5610

Forms to be Completed Prior to First Appointment

Please Print Out and Complete the Following Forms Prior to Your First Appointment.

Adult Intake Packet or Child Intake Packet

Or individually:
1.  Practice Policies and Agreement

2.  Insurance Information Form
3.  Authorization to Obtain and Release Information Form
      Please print out and fill one out each for 
          your primary care doctor or pediatrician
          your therapist (if applicable)

          anyone else you wish for me to communicate with, send, or receive records from (school, another healthcare provider or institution)

4.  Child / Adolescent Intake Form  OR  Adult Intake Form
5.  Please review my Notice of Privacy Practices

Additional Forms

Card on File for Payment
Vanderbilt ADHD Parent Rating Scale
Vanderbilt ADHD Teacher Rating Scale

Your privacy is of the utmost importance to me. In general, I do not keep physical records which are prone to theft and fire. In addition to physical security and shredding, I utilize several services that increase your privacy while still maintaining record keeping and communication requirements.