E-Forms

Click on a link to open file. Print for your convenience.

For new patients: Intake paperwork

• STARS MR-187: Financial & Privacy Policies
• STARS MR-186: Attendance & Cancellation Agreement
• STARS MR-137: Protected Health Information/ Communication Log Sheet
• STARS MR-183: Patient Profile (Work Hardening/ Work Conditioning Only)
• STARS MR-239: Patient Profile (Functional Capacity Assessment Only)
• B-193: Patient Rights & Responsibilities
• B-378: Notice of Privacy Practices

**For forms in Spanish, please contact our office.

For new patients: Testing Forms

• STARS MR-118: Back School Pre-Test
• STARS MR-121: BECK Inventory
• STARS MR-124: Pain & Impairment Relationship Scale
• DASS: Depression, Anxiety, Stress Scale (DASS for Work Conditioning clients only)

Download a WorkSTAR map
(near Saint Alphonsus Regional Medical Center off of Emerald Street)