Scheduling an Appointment

We are open for appointments Monday through Friday 8:00 - 5:00 p.m. Please contact us for information on how to prepare for
your first visit and what to bring with you to the Center.


Please bring the following to your first appointment:

Name, address, phone number and fax number of all current physicians, psychotherapists, and any past psychiatric treatment
providers

A complete list of all of your current and recent medications, (including over-the-counter medication and herbal preparations)
and/or prescription bottles

Copy of any Medical Records in your possession

Patients under the age of 18 should bring their most recent school behavior report, grade card and/or a symptom checklist
completed by teachers

If you would like to use your medical insurance, please bring a copy of your insurance card and any other information required for
submitting your claims.


Most, but not all, clinicians at CBT accept Medicare and most major insurance plans. We will help you to confirm your coverage prior
to making an appointment. Please contact our business office to discuss your individual insurance and payment needs.

Prior to your first appointment, please return completed copies of forms below.  If you can not download the forms, please contact
our office. Thank you!
Office Hours

Monday - Friday 8am - 6pm

Closed on all major holidays
Closed for lunch  12noon -
1:30pm
1.  Patient Registration Form
2.   Pre-Screen Information Form
6. Diagnostic and Symptom Screen
7. Depression Screening Checklist
centerforbrieftherapy.com
The following forms are available for you to download (in Microsoft Word) prior to your first appointment.  If you are unable to
download the forms, please contact Laura Stone, our Office Manager, or Lois Burrey, our Administrative Assistant at
260-969-5583 for assistance. Thank you.
CBT The Center for Brief Therapy, PC, 10319 Dawson's Creek Blvd, Suite J, Fort Wayne, Indiana, USA 46825
260-969-5583; fax 260-969-5584; email: freemancbt@aol.com
3. New Patient Information Form
4.   CBT Privacy Practices
5. Release of Information : Please print out two forms. Fill out one
form with information to the left with a significant other and
another form with your primary care practitioner (usually family
Doctor) and bring with you to your first appointment or fax.
8. Mood Disorder Questionnaire for Bipolar Screening.
9. Audit  Alcohol Use Disorder screening form (pdf).
NOTE: This is a pdf file so you must have Adobe Acrobat reader.
If you do not have this program, you can install it using by
clicking the icon to the left.
Download free Adobe Acrobat Reader
Click here to leave this website and go to
Adobe Website to download the free software
to open the files that are marked "pdf"
10. Mood Chart (PDF)