forms

To get started we will need some information and some forms.  You can complete these at your first walk-in visit, or you can print them and prepare them before you visit with us.  To view and print any form, click any form below.

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Please take our Family Re-Entry Survey here. 

Your family’s safety and the safety of our staff is of the utmost importance to us. We want your input on the following questions as we consider options for how best to continue to provide services for your family. This is for planning purposes only as the Clinic is not yet offering in person visits. Your answers will be kept confidential. We will not be collecting your name or other identifying information.

ENGLISH

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• Satisfaction Survey - Youth/Client

• Satisfaction Survey - Caregiver

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• Covid-19 Health Screening

** At this time, these forms are in English only.  Spanish forms will be posted once available. **

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Follow-up Assessments **

• Outpatient Caregivers

• Outpatient Youth and Clients

• TF-CBT

• MATCH

** At this time, these forms are in English only.  Spanish forms will be posted once available. **

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• CATCH Client Satisfaction Survey

• Notice of Privacy Practices Pamphlet

• Notice of Privacy Practices Acknowledgement

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• How to: Create an Email Address​

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SPANISH

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• Encuesta de Satisfacción - Joven/Cliente

• Encuesta de Satisfacción de la Familia

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• CATCH encuesta de satisfacción del cliente
   

• Notificación de prácticas de privacidad

• Notificación de prácticas de privacidad reconocimiento del cliente
   

• Cómo crear una dirección de correo electrónico

HIPAA Medical Record Forms

Please return all forms to a Clifford Beers location or via fax (203) 553-7344

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• Medical Record Release Form - English

• Medical Record Release Form - Spanish

• Request for Accounting of Disclosures​

• Request for Amendment of PHI

• Request for Confidential Communications

• Request for Restriction on Uses and Disclosures of PHI

• Revocation of Permission to Share Information

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