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.
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
** At this time, these forms are in English only. Spanish forms will be posted once available. **
Follow-up Assessments **
** At this time, these forms are in English only. Spanish forms will be posted once available. **
SPANISH
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Poliza de asistencia*
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Notificación de prácticas de privacidad reconocimiento del cliente
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Consentimiento para el tratamiento – menor con consentimiento del custodio legal
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Consentimiento para el tratamiento – menor sin consentimiento del custodio legal
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Consentimiento para el tratamiento – adulto con conservador*
*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