PROVIDERS FOR HEALTHY LIVING
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We are glad that you have entrusted us with your care. We strive to live up to our goal of instilling hope into every interaction with you.

​If you need a medication refill, ADHD rating scales for you or your child's teachers, or a release of information form, the links are located below.

As always, we appreciate and welcome your feedback, so feel free to send us an email if there are other items you'd like to see in this section of our website or have suggestions about how we can improve our services or operations.
Current Patient Forms - Locate the form you need then click to access it.

  • Consent for Online/Virtual Mental Health Treatment
  • Contact Preferences Disclosure Form
  • Controlled Substance Agreement - required for all patients receiving stimulants from our office - email completed form to patient@providersforhealthyliving.com after completion
  • Credit Card Authorization Form - email completed form to patient@providersforhealthyliving.com after completion
  • Financial Agreement for Psychological Testing Services
  • Informed Consent for Mental Health Treatment
  • Medication Refill Request Form
  • Notice of Privacy Practices
  • Office Policies
  • Numbers to Call in Crisis or to Seek Help
  • Paperwork Completion Request Form
  • Patient's Bill of Rights
  • Permission for Minors of Divorced/Separated Parents to Obtain Medical Treatment​ - required for all minors whose parents are divorced or separated - email completed form to patient@providersforhealthyliving.com after completion
  • Rating Scales for Objective Evidence-Based Treatment
  • Release of Information Form - required before records can be sent to or received from another facility or provider - email completed form to patient@providersforhealthyliving.com after completion

Click Here to Complete a New Patient Registration Form Today and Get Help Soon!


LOCATED AT 341 N MAITLAND AVE, STE 340, Maitland, fl 32751

Telephone and fax -
​407-219-3281

Email (do not use for medication refill requests or in emergency situations) - patient@providersforhealthyliving.com

  • Home
  • Our Services
  • Virtual Visits
  • Our Team
  • Location/Address
  • Insurances Accepted
  • New Patient Information and Forms
  • Current Patient Information
  • Make a Payment
  • Refer a Patient
  • Patient Feedback
  • Reviews