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For Appointments Call 833-350-1113
Patient Portal
Pay My Bill
Schedule an Appointment
For Appointments Call 833-350-1113
Pay My Bill
Patient Portal
Schedule an Appointment

Forms for Behavioral Health Patients

If you have an in-person visit, please print and fill out all forms and bring them with you to your appointment. All forms can be handed to the front desk during check-in.

English

Patient Information Form
Consent for Treatment
Notice of Privacy Practices
Mandatory Disclosure Integrated Behavioral Health
BH Release of Information
BH Protected Health Information Request
Patient Information Brochure
BH Acknowledgement of Treatment Goals and Service Planning
Advance Beneficiary Notice
Authorization for Designated Client Representative
Patient Decision Against Medical Advice

Spanish

Informacion del Paciente
Consentimiento para Tratamiento
Aviso de Practicas de Privacidad
Servicios Integrado de Salud Conductual
Autorizacion de Salud Conductual para Divulgar Intercambiar Informacion de Salud Protegida
Solicitud de Information Medica Protegida de Salud Conductual
Informacion Para el Paciente
Reconocimiento de los Objetivos del Tratamiento y Planificacion de Servicios
Aviso Anticipado de no Cobertura al Beneficiario
Decision del Paciente Contra el Consejo Medico

Additional Forms for Patient Under 18 or Adolescents

Adolescent Visit Consent
Unaccompanied Minor
Partial Parental Delegation Authority
Financially Independent Minor
Consentimiento para una Visita de Tratamiento de un Adolecente
Menor No Acompanado
Delegacion de Autoridad Parcial de los Padres para el Tratamiento
Menor de edad Financieramente Independiente