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.

ENGLISH

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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

• Level of Care Screener

• Insurance Registration Form

• Bill of Rights

• Attendance Policy

• Notice of Privacy Practices Pamphlet

• Notice of Privacy Practices Acknowledgement

• Grievance Protocol

• Caregiver goals

• Client goals

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• Inquiry Form – Child/Youth

• Inquiry Form - Adult 

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• Consent for Treatment – Minor with Legal Guardian

• Consent for Treatment – Minor without Legal Guardian

• Consent for Treatment – Adult

• Consent for Treatment – Adult with Conservator

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• Release of Information – Minor/Conserved

• Release of Information – Adult

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SPANISH

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• CATCH encuesta de satisfacción del cliente

• Nivel de cuidado

• Formulario de registro para el seguro mèdico

• Declaración de los derechos del cliente

• Poliza de asistencia*

• Notificación de prácticas de privacidad

• Notificación de prácticas de privacidad reconocimiento del cliente

• Protocolo para quejas/querellas

• Metas del Cuidador*

• Metas del Cliente*

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• Formulario de Consulta - niño

• Formulario de Consulta - adulto

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• Consentimiento para el tratamiento – menor con consentimiento del custodio legal

• Consentimiento para el tratamiento – menor sin consentimiento del custodio legal

• Consentimiento para el tratamiento - adulto

• Consentimiento para el tratamiento – adulto con conservador*

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• Permiso para compartir información - menor

• Permiso para compartir información - adulto
   

*ROJO: aún no está disponible en español

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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