Iowa Client Forms

Outpatient Services in Iowa

New Client Forms

Our new patient forms can now be completed online. If you are receiving services through your Employee Assistance, Church Assistance or School Assistance Program, please use the forms that are labeled EAP on the corresponding tab for your state.

Please complete the appropriate form at least 24 hours before your first appointment.

If you do not have an appointment, please call 866.852.4001.

IOWA ONLINE NEW PATIENT FORMS

These forms are only for patients who are:

  • Receiving services at the Pine Rest Pella Clinic located in the state of Iowa
  • OR receiving Telehealth Services while located in the state of Iowa
If you are accessing services using your Pine Rest Employee Assistance (EAP), Church Assistance (CAP) or School Assistance (SAP) program, please use the EAP forms for your state.

Your Form should be completed and submitted at least 24 hours before your appointment.

The online form is quite comprehensive and could take approximately 30 minutes to complete. Please complete all forms to the best of your ability.

To start, click on the button below which lists the age of the person being treated. A new window will open asking you to set up an account so your form can be saved and completed later, if needed.

Iowa EAP Online New Patient Forms

Please use these forms if you are using your Pine Rest Employee Assistance Program, Church Assistance Program or Student Assistance Program to access services:

  • At a Pine Rest Pella Clinic located in the state of Iowa
  • OR through Telehealth Services while located in the state of Iowa

Your Form should be completed and submitted at least 24 hours before your appointment.

The online form is quite comprehensive and could take approximately 30 minutes to complete. Please complete all forms to the best of your ability.

To start, click on the button below which lists the age of the person being treated. A new window will open asking you to set up an account so your form can be saved and completed later, if needed.

Printable New Client Forms for Outpatient Clinic Patients Only

If you are a Telehealth client, you must complete the online forms.


Please bring a completed New Client Form to your first visit if you do not complete the online form.

Print out the appropriate form for you, your child or your patient. The form must be completed in black or blue ink.

Child: Age 11 or under

Adolescent: Age 12 – 17

Adult: Age 18 and over

Release of Information Forms

In order to share your information with your healthcare provider(s), you will need to complete and sign a Release of Information form.

Pella Clinic Patients: you must use the downloadable/printable form. A sample has also been supplied. Please complete in black or blue pen and fax to 616.281.6394.

Iowa Telehealth Patients: you must use the online version below.

*In compliance with HIPAA, we can only share information with you if the patient has signed a release of information. If you are unable to get the information that you are requesting, guide the patient through completing the release of information following the example and directions provided. Fax the completed release of information to the appropriate location with a statement about what information you are requesting.

To schedule a new outpatient appointment, call 866.852.4001.