Helpful Forms

INTAKE AND CONSENT FORMS

First-time client, please download review and complete the following two forms below Intake form and Outpatient service consent form.

(IN HOUSE CLIENTS ONLY)

DOC: INTAKE FORM 2014 OUTPT

PDF: INTAKE FORM 2014 OUTPT

DOC:  HIPAA_CONSENT 12-10

PDF:HIPAA_CONSENT 12-10

DOC: OUTPATIENT-SERVICES-CONSENT-FORM-12-10

PDF:  OUTPATIENT-SERVICES-CONSENT-FORM 12-10

DOC: Authorization for Release of Confidential Information 12-10

PDF: Authorization for Release of Confidential Information 12-10

Please fill them out in their entirety and bring them to your first visit.

(COMMUNITY FOCUS)

DCF Documents for referrals

DOC:BHCS, LLC Referral-intake Form-DCF 2013

PDF: BHCS, LLC Referral-intake Form-DCF 2013

DOC: Authorization for Release of Confidential Information- 2013

PDF:Authorization for Release of Confidential Information- 2013

DOC:CONSENT FOR ROUTINE CARE 2013

PDF:CONSENT FOR ROUTINE CARE 2013

  If you would like me to coordinate care with another provider you will need to complete the release of information form. Release of information is to speak with other providers such as school psychologist, psychiatrist other providers, etc. Have a look at casino online Canada and win jackpot!