Patient Forms

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  New Patient Paperwork

  Please complete these forms and bring them with you to your first appointment. Please arrive 15-20 minutes prior to your appointment time with your photo ID and a copy of your insurance card.

  Get Started: New Patient Paperwork
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  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.

  Get Started: Authorization to Release Health Information (ROI)
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  Client Insurance Form

  If you have new or updated insurance information, please complete this form and bring it to your next appointment with a copy of your insurance card. Also contact billing at ext. 252 to ensure proper billing of your claims.

  Get Started: Client Insurance Form

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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  TelePsych Informed Consent

  If you are a client who is interested in TelePsych services, please complete this form and fax it (860) 823-1170.

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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.

  Get Started
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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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