Forensic Services • Therapy Services • Psychological Evaluations • Benson Psychological Services, PC • Fargo, North Dakota
  Benson Psychological Services - Fargo, North Dakota   Benson Psychological Services, PC
1308 23rd Street South, Suite G
Fargo, ND 58103
Phone 701.297.7540
Fax 701.297.6439
 
Benson Psychological Services - Fargo, North Dakota
Benson Psychological Services - Fargo, North Dakota
Benson Psychological Services - Fargo, North Dakota
 
 

Benson Psychological Services, PC

Dr. Stacey Benson
1308 23rd Street South,
Suite G
Fargo, ND 58103
Phone 701.297.7540
Fax 701.297.6439

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Benson Psychological Services, PC of Fargo, North Dakota
Forms

 
 

Here is a list of forms you will need to review as part of our opening paperwork. Please click on the links shown below to see the individual forms, and print them for your own records.

If you have questions, please » Contact Us «. We look forward to hearing from you and answering your questions.

Thanks !

       
    Notice of Privacy Practices – Brief Version
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
       
    New Adult Patient Questionnaire
THIS FORM WILL ALLOW US TO LEARN MORE ABOUT YOU AND WHY YOU HAVE CHOSEN TO SEEK HELP AT THIS TIME. PLEASE FILL OUT THIS FORM PRIOR TO YOUR FIRST APPOINTMENT.
       
    Outpatient Services Contract
THIS DOCUMENT CONTAINS IMPORTANT INFORMATION ABOUT OUR PROFESIONAL SERVICES AND BUSINESS POLICIES. PLEASE REVIEW IT CAREFULLY.
       
    Financial Agreement for Forensic Evaluations
THIS DOCUMENT CONTAINS IMPORTANT INFORMATION ABOUT YOUR FINANCIAL AGREEMENT FOR FORENSIC EVALUATIONS. PLEASE REVIEW IT CAREFULLY.
       
    Release of Information
THIS DOCUMENT CONTAINS IMPORTANT INFORMATION ABOUT YOUR AUTHORIZATION TO DISCLOSE INFORMATION. PLEASE REVIEW IT CAREFULLY.
       
    Psychological Evaluation Questionnaire
THE PURPOSE OF THIS QUESTIONNAIRE IS TO OBTAIN A COMPREHENSIVE PICTURE OF YOUR BACKGROUND. DURING A LATER INTERVIEW, YOU WILL HAVE AN OPPORTUNITY TO DISCUSS THESE CONCERNS IN MORE DETAIL, IF NECESSARY. YOU WILL NEED TO HAVE THIS FORM COMPLETED PRIOR TO YOUR SCHEDULED INTERVIEW.
       
    New Child Patient Questionnaire
THIS DOCUMENT CONTAINS IMPORTANT INFORMATION ABOUT YOUR CHILD'S BEHAVIORAL HEALTH. PLEASE REVIEW IT CAREFULLY.
       
    Adoption Pre Screening Evaluation
The purpose of this questionnaire is to obtain some basic background information. The agency that you are working with has asked us to have you complete an MMPI-2. The MMPI-2 is the most commonly given psychological test in the United States. When you come to the appointment we will carefully go over the test and what you can expect. Most people complete the testing in 60-90 minutes. Under most circumstances we can score it, and give you feedback on your results right away.
       
    Risk Assessment Questionnaire
The purpose of this questionnaire is to obtain a comprehensive picture of your background. During a later interview you will have an opportunity to discuss these concerns in more detail. YOU ARE NOT BEING ASKED TO FILL IN IDENTIFYING INFORMATION ABOUT VICTIMS. I am requesting however, for you fill in information about the sex of victims, ages, degree of force, and so forth. IF YOU REPORT SPECIFICS, SUCH AS A CHILD VICTIMS NAME OR OTHER IDENTIFYING INFORMATION, THIS MAY BE REPORTED TO THE APPROPRIATE AUTHORITIES. Again, you are not being asked for such information.
       
Dr. Stacey Benson
Benson Psychological Services, PC
1308 23rd Street South, Suite G
Fargo, ND 58103
Phone 701.297.7540
Fax 701.297.6439
 
     
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