Healthcare Professionals

Being required by your licensing board to get a mental health and/or substance abuse evaluation can be cause many emotions to come up, from fear to anger.  We’re here to help every step of the way and make it easier and get you back to doing what you love: taking care of others.


Below are the forms we’ll need to get started.


INSTRUCTIONS: Please print and complete, but do not sign, the Registration, Current Symptom List, Substance Use History, Medical History, and appropriate Authorization for Release of Information forms.


Registration for Assessment 


Authorization for Release of Information to the Kentucky Board of Medical Licensure


Authorization for Release of Information to the Kentucky Board of Nursing


Authorization for Release of Information to the Kentucky Board of Pharmacy


Current Symptom List


Substance Use History


Medical History


The forms on this page require Adobe Reader.


David can be reached at

859-309-6978


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