New Client Forms

Get new client paperwork to start receiving behavioral health services.

Trên trang này

English
Español (Spanish)
አማርኛ (Amharic)
عربي (Arabic)
中文 (Simplified Chinese)
한국인 (Korean)
Pусский (Russian)
Soomaali (Somali)
Tiếng Việt (Vietnamese)

Complete and sign these forms before your first visit. For documents in another language, please contact us.

English

Consent for Treatment (45.26 KB)

Release of Information (169.16 KB)

Email Consent Form (41.71 KB)

Text Message Consent form (41.74 KB)

Español (Spanish)

Autorización para servicios de tratamiento (Consent for Treatment) (52.44 KB)

Autorización para la divulgación departamento de salud de información (Release of Information) (123.83 KB)

Autorización para correo electrónico (Email Consent) (122.49 KB)

Autorización para mensajes de texto (Text Message Consent) (122.13 KB)

አማርኛ (Amharic)

እንዲለቀቅ የተሰጠማረጋገጫ (Release of Information) (302.54 KB)

የኢሜይል ፈቃደኝነት ቅጽ (Email Consent) (202.73 KB)

የደንበኛ የጽሁፍ መልእክት ፈቃደኝነት ቅጽ (Text Message Consent) (196.85 KB)

عربي (Arabic)

موافقة لتلقي الخدمات العلاجیة (Consent for Treatment) (91.69 KB)

الإفصاح عن المعلومات (Release of Information) (190.47 KB)

الموافقة على استخدام البريد الإلكتروني (Email Consent) (69.31 KB)

الموافقة علي الرسائل النصية (Text Message Consent) (68.81 KB)

中文 (Simplified Chinese)

治疗服务同意书 (Consent for Treatment) (161.29 KB)

信息发布授权书 (Release of Information) (131.65 KB)

电子邮件同意书 (Email Consent) (507.09 KB)

短信同意书 (Text Message Consent) (490.21 KB)

한국인 (Korean)

치료 서비스에 대한 동의 (Consent for Treatment) (141.42 KB)

정보 공개 승인 (Release of Information) (6.69 MB)

이메일 동의 (Email Consent) (185.13 KB)

문자메시지 수신 동의 (Text Message Consent) (181.51 KB)

Pусский (Russian)

Согласие на лечебные услуги (Consent for Treatment) (99.1 KB)

Разрешение на раскрытие Информации (Release of Information) (167.03 KB)

Согласие на обмен электронными письмами (Email Consent) (290.43 KB)

Согласие на обмен текстовыми сообщениями (Text Message Consent) (286.39 KB)

Soomaali (Somali)

Ogolaanshaha Adeegyada Daaweynta (Consent for Treatment) (53 KB)

Oggolaanshaha Bixinta Xogta (Release of Information) (217.97 KB)

Ogolaanshaha Email-ka (Email Consent) (185.13 KB)

Ogolaanshaha Fariinta La Isugu Diro Telefoonka (Text Message Consent) (120.97 KB)

Tiếng Việt (Vietnamese)

Đồng ý cho các Dịch vụ Điều trị (Consent for Treatment) (93.31 KB)

Giấy Cho Phép Tiết lộ Thông tin (Release of Information) (146.52 KB)

Đồng ý nhận qua Email (Email Consent) (217.24 KB)

Đồng ý nhận Tin Nhắn tin bằng Văn bản (Text Message Consent) (215.36 KB)

Lần cuối được xem xét Ngày 15 tháng 7, 2024

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