Complete Behavioral Health

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:
HIPAA Compliance Information
HIPAA Privacy Notice Acknowledgment “By signing below, I acknowledge that I have been informed that my personal health information is protected by the Health Insurance Portability and Accountability Act (HIPAA). I understand that my information will be kept confidential and only shared with authorized individuals or entities, as permitted or required by law. I have been provided with a copy of the organization’s HIPAA Privacy Notice, which outlines my rights and the ways in which my information may be used and disclosed. I consent to the use and sharing of my health information as described in the Privacy Notice.