New Client Forms

Please download and complete the forms below if you are a new Client:

CPI's AUTHORIZATION FOR THE REQUEST, RELEASE & EXCHANGE OF CLIENT’S HEALTH/ or MENTAL HEALTH INFORMATION

CPI may disclose, release and exchange information about:

Me (Name):

D.O.B.

Client's Name

D.O.B.

To:

Primary Care Physician/ Office / Clinic:

Address:

City:

State:

Zip:

Phone#:

Fax#

And/Or :

Other Office or Party:

Address:

City:

State:

Zip:

Phone#:

Fax#

Orally

Written Copies

By signing I acknowledge that such release discloses the fact that mental health/health services have been/are being provided.

This disclosure of information* is required for the following purpose(s): ): (check applicable areas)

Evaluation

Treatment Planning/Course

Other - Specify ________________________________________

and shall be limited to releasing the following types of information (initial all applicable areas):

from (date required):

to ( end date required) :

*The information disclosure under this authorization may be subject to re-disclosure by the recipient if allowed or required by law. This authorization becomes effective (Month/Day/Year)

This authorization may be revoked in writing by the undersigned at any time except, to the extent that action has already been taken. If not revoked, it shall terminate in one year. Once this information is disclosed, how the recipient further discloses it may no longer be protected under federal privacy law (HIPAA).

I understand that I may receive a copy of this authorization.

Request A Copy

Signature of Client:

Date:

Signature of Parent/Guardian

Date:

Signature of Witness

Date:

*For CPI Office Personel Only*

RECORD OF RELEASE OF INFORMATION

The following information was released to the named party specified on the front of this form. Identify the specific dates of the reports, records, items released.

Please print out this page after you have filled it out, then sign it and bring it with you on your first visit.

CPI's Informed Consent Form 2020