Complete Behavioral Health

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CBH FORMS

CBH Forms

Welcome to CBH Forms where all the forms are available in one place for your convenience!

We know filling out forms can be a pain. We made it EASY and convenient just for YOU! Forms can be filled online directly (Submit Online) or using fillable pdf or print (Fillable PDF or Print) and fill out with a pen and return to us during your first appointment.

INTAKE

CONSENT FOR OUTPATIENT TREATMENT

OFFICIAL FINANCIAL POLICY AND BILLING AGREEMENT

AUTHORIZATION FOR DISCLOSURE OF INFORMATION

  • INTAKE
  • CONSENT FOR OUTPATIENT TREATMENT
  • OFFICIAL FINANCIAL POLICY AND BILLING AGREEMENT
  • AUTHORIZATION FOR DISCLOSURE OF INFORMATION

INTAKE Information

Marital Status

Please list children and ages

Emergency Contact

Insurance Information

CONSENT Information

FINANCIAL Information

Payment:

AUTHORIZATION Information

Disclosure of Information

Authorization is hereby given to exchange information in written, verbal, or electronic form regarding the above named individual between the following agencies and/or individuals to be used for the purpose(s) of:

I authorize the following agency or individual (please include address):

To release and /or receive information from the following agency or individual (please include the address):