Patient Forms
Thank you for choosing Boulder Community Health for your outpatient rehabilitation needs. We look forward to partnering with you to help you achieve your rehabilitation goals.
Prepare for Your First Visit (Evaluation)
- Download, print and complete the appropriate forms. (Forms require Adobe Reader: Free download of Adobe Reader)
- Bring forms with you to your first appointment.
- Bring your physician's prescription/referral if required by your insurance.
- Bring your health insurance card, photo identification, form of payment and a list of current medications.
- Wear comfortable clothing.
- Plan to check in 15 minutes prior to your evaluation time.
- At the Boulder location, please allow additional time to get from the parking lot to the check in desk on the 2nd floor. (Enter through the hospital's main entrance on Balsam Avenue. Wheelchairs are available at the Balsam entrance if needed. Follow the signs to the elevators and proceed to the 2nd floor.)
Forms for All Patients
- Joint Notice of Privacy Practices
- Joint Notice of Privacy Practices - Spanish
- Rehabilitation Services - Financial Policy
- Fall Risk Screening - Complete if 65 years old or greater
In addition to the forms above, please complete forms below based on your type of evaluation.
Counseling Evaluation Forms
- Beck's Depression Inventory
- Patient Questionnaire – Counseling
- Patient Questionnaire-Accident – Complete if you were involved in an accident (in addition to the general questionnaire above).
Hand Therapy Evaluation Forms
Lymphedema Therapy
Occupational Therapy Evaluation Forms
Physical Therapy Evaluation Forms
Complete 1 of the following based on the primary reason for your Physical Therapy evaluation:
- Neck Disability Index - If your primary problem is your neck
- Modified Low Back Pain Disability Questionnaire - If your primary problem is your back
- Disability of Arm, Shoulder and Hand (DASH) - If your primary problem is your upper extremity (shoulder, arm, elbow, hand)
- Lower Extremity Functional Scale - If your primary problem is your lower extremity (hip, knee, ankle)
- Optimal - If your primary problem is more general or does not fall into one of the above categories
Speech-Language/Cognitive Therapy Evaluation Forms
Complete 1 of the following questionnaires based on the primary reason for your Speech Therapy evaluation:
Speech-Language-Cognitive Therapy - Intake Questionnaire - If your primary problem is speech, language or cognition
Speech-Language Therapy for People with Parkinson's Disease - Intake Questionnaire - If you have Parkinson's Disease
Swallowing Therapy - Intake Questionnaire - If your primary problem is swallowing
Voice Therapy - Intake Questionnaire - If your primary problem is your voice
Call 303-415-4400 if questions.