Adult Intake Form

March 31, 2018April 2, 2022pabh2017

Adult Intake Form

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Schedule Appointment

Office: (605) 348-6500

If you are a new patient inquiring about making a first appointment, please click on the Request Services button above. Upon receiving your request we will reply to you with a phone call. Thank you.

Please do not email or use the form below to schedule an appointment.

Rapid City Office
1818 W Fulton Street Suite 201 Rapid City SD 57702

Email: rappsy18@gmail.com

Custer Office (Dr. Perrenoud only)
14 West Mount Rushmore Road, Suite C, Custer, SD 57730

Clinicians

Margaret D. Kelsey, Ph.D.
Jennifer J. Kozel, Ph.D.
Trisha T. Miller, Ph.D., Inc.
Mark Perrenoud, Ph.D, Inc.
Lynette R. Quast, Ph.D
Laura Hughes, PsyD

NEW CLIENT FORMS

Email/Texting Consent Form
*Childhood History Form
*Adult Intake Form
Release of Information Form
Client Registration Form
Telehealth Consent Form
Your rights under the No Surprises Act
—(Clients who are self-pay or provider who is out of network)

*not all providers require the Childhood History Form or the Adult Intake Form – please inquire with office.

PSYCHOLOGICAL ASSOCIATES OF THE BLACK HILLS | Rapid City

1818 W Fulton Street Suite 201
Rapid City SD 57702

Office: (605) 348-6500

Fax: (605) 341-7409
Monday - Friday
8am - 5pm & by appointment

PSYCHOLOGICAL ASSOCIATES OF THE BLACK HILLS | Custer Office (Dr. Perrenoud only)

14 West Mount Rushmore Road, Suite C, Custer, SD 57730

Office: 605-348-6500

Fax: (605) 341-7409
Hours: By appointment only

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DIRECTIONS TO OFFICE

DOWNTOWN RAPID CITY LOCATION | If you are coming from downtown Rapid City: drive west on Main St., turn left on Jackson Blvd., turn left onto W Fulton St. (the very first stop light you come to). Our office building is on the left up the hill. Drive to the TOP of our buildings drive (to the East entrance door). *Please do not enter through the South entrance door at the bottom of the drive.*

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