Patient Forms
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New Patient Paperwork
Get Started: New Patient PaperworkPlease complete these forms in their entirety, sign all necessary signature lines and submit electronically. A member of the Intake Department will contact you to discuss scheduling an appointment.
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Authorization to Release Health Information (ROI)
Get Started: Authorization to Release Health Information (ROI)Please complete this form if you would like CBHA to disclose your personal health information with anyone other than yourself or to obtain records from your previous providers.
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Client Insurance Form
Get Started: Client Insurance FormPlease complete this form, sign the necessary signature line and submit electronically. Email photos of the front and back of your insurance card to billing@cbhapc.com.
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Telepsychiatry Informed Consent
Get Started: Telepsychiatry Informed ConsentIf you are a client who is interested in TelePsych services, please complete this form.
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Client Agreement for Buprenorphine (SUBOXONE) Treatment
Get Started: Client Agreement for Buprenorphine (SUBOXONE) TreatmentPlease read and review the full Suboxone Contract, then sign and submit this form if you are seeking to enroll into the Suboxone Program.
Upon finishing any of the necessary forms below, please fax or email them following the provided instructions. If the instructions do not include an email or fax, please send the completed forms to supportstaff@cbhapc.com.
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General Office Policy
Attached you will find the most up-to-date office policies regarding; canceling or rescheduling of appointments, NO SHOW/LATE CANCELLATION policy, medication refills, paperwork/forms or medical records requests.
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Financial Policy
Attached you will find the most up-to-date financial policies regarding; acceptable payment methods, service/administrative fees, No Show/Late Cancellation fees and Collection fees.
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Client Intake Form
If you are seeking to become a new client of CBHA please complete this form and fax it to (860) 823-1170, drop if off at any CBHA location or email it to intake@cbhapc.com. A member of the Intake Department will contact you within 24-48 hrs of receipt.
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Intake Assessment Form
If you are a provider and wish to refer your client for out-pt treatment from a higher level of care, please complete this form and fax it to (860) 823-1170. A member of the Intake Department will contact you within 24-48 hours of receipt.
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TMS Referral Form
If you are a provider and wish to refer your client for Transcranial Magnetic Stimulation, please complete this form and fax it to (860) 823-1170 or email intake@cbhapc.com The TMS Coordinator will contact you within 24-48 hours of receipt.
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Spravato Referral Form
If you are a provider and wish to refer your client for Spravato, please complete this form and fax it to (860) 823-1170 or email intake@cbhapc.com The Spravato Coordinator will contact you within 24-48 hours of receipt.
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Specialized Services Intake Assessment Form
If you are a provider and wish to refer your client for out-pt substance abuse treatment from a higher level of care, please complete this form and fax it to (860) 823-1170. A member of the Intake Department will contact you within 24-48 hours of receipt.
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Therapy Verification Form
For clients who are required to seek therapy and see a provider outside of CBHA, this form is required to show proof of on-going treatment.
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