Psychological Services of Pendleton, LLC

An Eastern Oregon landscape.

client forms

The staff at Psychological Services of Pendleton, LLC utilize a variety of forms and questionnaires. As a courtesy to our clients, we have made some of these forms available on this site. Documents are listed by clinician, and may be viewed on your web browser, printed, or downloaded and saved to your computer. Forms are provided in PDF format. If you do not already have a program capable of reading PDF files, you may download the free Adobe® Reader® here.

Dr. Templeman's Forms

Dr. Umphred's Forms

Dr. Kollross's Forms

English

Spanish

  • Consent to Treatment
  • Consent to Treat Children of Divorced Parents
  • HIPAA Consent
  • Consent to Assessment
  • Form only to be completed if you are requesting a psychological evaluation or neuropsychological evaluation. Please contact our office by phone for these requests (541-278-2222).
  • Release Two Way
  • This is a release of information form. This form is only to be filled out if you would like this provider to obtain or coordinate records with another person or provider.
  • Release One Way from Clinician
  • This is a release of information form. This form is only to be filled out if you would like this provider to obtain or coordinate records with another person or provider.
  • Release One Way to Clinician
  • This is a release of information form. This form is only to be filled out if you would like this provider to obtain or coordinate records with another person or provider.
  • Release One Way to Clinician Confidential
  • This is a release of information form. This form is only to be filled out if you would like this provider to obtain or coordinate records with another person or provider.

Dr. Evans' Forms