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THRIVING KIDS PROJECT

SERVICES BY COUNTY

OUR INSTITUTE

Institute Programs & Resources

GUIDANCE CENTER

Clinical Services & Programs

Disclosure Of Information: Primary Care Physician, Doña Ana

FOR DOÑA ANA COUNTY ONLY. Intake forms are securely encrypted and HIPAA compliant.

  • Disclosure Of Information: Primary Care Physician
    ID #
  • MM slash DD slash YYYY
  • BY SIGNING BELOW I VERIFY THAT THERE IS NO PRIMARY CARE PHYSICIAN WHO CAN COLLABORATE WITH SOUTHWEST FAMILY GUIDANCE CENTER.

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • BY SIGNING BELOW I VERIFY THAT I DO NOT AUTHORIZE CARE COLLABORATION WITH MY PRIMARY CARE PHYSICIAN.

  •  

    IF THE CLIENT IS 14 YEARS OF AGE OR OLDER, THEY MUST SIGN THIS DOCUMENT THEMSELVES.


    IF THE CLIENT IS UNDER 14 YEARS OF AGE, THE DOCUMENT MUST BE SIGNED BY PARENT, GUARDIAN, OR LEGAL REPRESENTATIVE.


  • MM slash DD slash YYYY

PRIMARY PHONE LINE
(505) 830-1871

PRIMARY FAX LINE
(505) 830-0040

Albuquerque Main Office

2221 Rio Grande Blvd NW
Albuquerque, NM 87104
(505) 830-1871

Albuquerque East Office

2612 Texas St. NE
Albuquerque, NM 87110
(505) 830-1871

Las Cruces: Telshor Office

755 S. Telshor Blvd, Suite 201B
Las Cruces, NM 88011
(575) 524-6820

Las Cruces: Don Roser Office

1401 Don Roser, Suite F1-F2
Las Cruces, NM 88011
(575) 524-6820

Santa Fe Office

4001 Office Court Dr. Suite 603
Santa Fe, NM 87507
(505) 310-4764

© SOUTHWEST FAMILY GUIDANCE CENTER & INSTITUTE | ALL RIGHTS RESERVED | WEBSITE BY MERIDIANSIX SANTA FE-ALBUQUERQUE | LEGAL

© SOUTHWEST FAMILY GUIDANCE CENTER & INSTITUTE

ALL RIGHTS RESERVED | LEGAL | WEBSITE BY MERIDIANSIX