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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• 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

• 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 

• How to: Create an Email Address

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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

• Cómo crear una dirección de correo electrónico

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*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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