PATIENT FORMS
Child Guidance Center Patient Forms
You will receive these forms as part of your new patient welcome packet, but you can also print and complete them before your first visit.
Consent for Treatment
- You must sign this form to be a patient with us. The form has many parts, and you can choose whether you want to sign each part. A member of staff will be happy to walk you through the form.
- English
Rights and Responsibilities/Consent for Behavioral Health Treatment
- This form lets you know your rights and your responsibilities as our patient, and gives your consent for you or your child/dependent to be treated at CGC.
Release of Information
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- If you would like to request access to your health information, or allow another person or organization to access your health information, look at the options below, or visit any CHC site to fill out the forms in person. You can access your medical records, appointment history, test results, and more on the Patient Portal, myCHC.
- If you need to obtain or release information from CHC, click the link below:
Consent for Care of Minor by Proxy
- This form needs to be filled out if you would like someone other than a parent/guardian to bring your child/dependent to an appointment.
- English
- Spanish
- Portuguese
Permission to Share
- You will need to fill out this form if you would like someone to pick up medications, cancel appointments, or know treatment information about you or your child/dependent.
- English
- Spanish
- Portuguese
- Polish
Sliding Fee Scale Application
- We offer a sliding fee scale for our services. Any patient is able to fill out this form to see if they are eligible.
- English/Spanish
Notice of Privacy Practices