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.
  • English
  • Spanish
  • Arabic

Release of Information

  • You have the right to see your medical records. To do so, we will need you to fill out this form.
  • English
  • Spanish

 

    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

    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

    • This outlines your rights as a patient being treated by our agency.
    • English
    • Spanish