REQUIRED FORMS
General Intake
Medical History
Clinical Policies
Notice Of Privacy Practices
Notice Of Confidentiality Of Alcohol And Drug Abuse Patient Records
Financial Responsibility
Telehealth Consent
Proof Of Identity & Insurance
Disclosure Of Information: Primary Care Provider
OTHER FORMS
Permission For School-Based Services
Request For Services By A Minor (For Minors Only—Parents Do Not Complete)
Disclosure Of Information: General
Recording Consent
Protected Health Information Request
Document Upload Form
Fostering Family Forms
FOSTERING FAMILY: GENERAL INTAKE FORM
FOSTERING FAMILY: SERVICE POLICIES
FOSTERING FAMILY: NOTICE OF PRIVACY PRACTICES
FOSTERING FAMILY: RECEIPT OF NOTICE OF PRIVACY PRACTICES
Printable Intake Forms
Please find links below to our Client Intake Forms in PDF format.
Clients are advised to download and bring completed forms to their
intake appointment along with appropriate insurance information.
If you have any questions or need assistance, please call (505) 830 1871.
General Intake
Medical History
Clinical Policies
Notice Of Privacy Practices
Notice Of Confidentiality Of Alcohol And Drug Abuse
Receipt Of Notice Of Privacy Practices
Disclosure Of Health Information
Permission For School-Based Services
Request For Services By A Minor
Financial Responsibility
Telehealth Consent