Forms – Individual

If you have questions about a form, need assistance filling it out, or would like to schedule an appointment for services, please call us at 860-437-4550.

We are no longer accepting new IICAPS referrals.

After Hours Procedure
Authorization for Health Information Exchange
Authorization for Release of Information (Adolescent)
Authorization for Release of Information
BITSEA Parent
Center for Epidemiologic Studies Depression Scale – CAREGIVER
Child First Authorization to Use and Disclose Health Information
Child First Consent to Photography and Video
Circle of Security Parenting Group Permission to Participate
Client Outcome Measures – Adolescent
Client Outcome Measures – Parent
Client Rights and Responsibilities
Columbia Teen (11 years old +) – to be completed by teen
Columbia Teen (11 years old +) – to be completed by parent
CPSS-V-Caregiver
Drug Authorization and Consent
ECMH Classroom Support Opt Out Letter
Edinburgh Scale
FFT Family Self Report
Grievance Procedure
IICAPS Authorization for Release of PHI
MATCH Intake Packet 0-4 yr
MATCH Intake packet 5-6yr
MATCH Intake packet 7+yr
Medical Service Request
Ohio scales : Parent
Ohio scales : Youth
Parental Stress Scale-Caregiver
PCL-5 Periodic-Discharge-Caregiver
Perinatal Anxiety Screen
PKBS-2
Preschool Pediatric Symptom Checklist (PPSC)
PROMIS-Child
PROMIS-Parent
Proxy Application Authorization for Adolescents
Psychiatric Developmental History
Release of Information and Assignment of Benefits for Insurance
Reunification and Therapeutic Family Time Plan
Review of Systems
Psychiatric Medication Management Responsibilities
TEC
Telehealth consent
THS-Caregiver
Universal In-home Referral
In-Home Referral PDF
Updates and/or Discharge Packet
Vanderbilt-Parent
Vanderbilt-Teacher
Video and Audio Recording Release
Youth Child PTSD Checklist Caregiver
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