Patient forms
Five forms, and the one text that sends you the right ones.
You do not need to hunt for a link. Text (207) 241-2815, tell us whether you want telemedicine or an in-person visit, and the clinic texts you the form link that fits.
Register of forms
Relief Clinic LLC, Auburn, Maine
- I
Telemedicine Certification Form
Patients certifying by video from a phone or computer.
Completed for your telemedicine visit, any day from 10:00am to 8:00pm. Electronic copies are uploaded the same day.
- II
In-Person Certification Form
Patients seen at 216 Center Street, Auburn.
Completed for your in-person visit on Wednesday 12:00pm - 3:30pm or Friday 10:00am - 2:30pm. Bring your Maine driver's licence or state ID.
- III
Telemedicine Consent Form
Patients having a telemedicine visit.
Titled “Permission for Telemedicine Visits with Relief Clinic LLC.” Telemedicine visits with your provider are not recorded.
- IV
HIPAA form
All patients with anxiety, depression, PTSD or any other mental health problems.
Completed together with the PCL-5.
- V
PCL-5
All patients with anxiety, depression, PTSD or any other mental health problems.
Fifteen questions about the past month, answered on a 0 to 4 scale.
The original forms are hosted by a third party and are sent to patients by text rather than posted here. Relief Clinic LLC will not share your information with anyone, and we follow HIPAA.
About the PCL-5
Fifteen questions about the past month.
Every patient with anxiety, depression, PTSD or another mental health problem fills in the HIPAA form and the PCL-5. The form asks how much you were bothered in the past month, and to answer for how you felt not medicated.
If you are not sure whether it applies to you, ask first. Consultations are free.
Free consultationsHow much were you bothered by
- 0Not at all
- 1
- 2
- 3
- 4Extremely
Zero is not at all and four is extremely. Each of the fifteen questions gets one number from that scale.
How the forms reach you
- 1
Text (207) 241-2815 and say telemedicine or in person.
- 2
The clinic texts back the links for the forms you need.
- 3
Complete them for your visit. Approval is same day, and with telemedicine your electronic copies are uploaded the same day.