Telehealth Pre-Assessment Forms
Consent for Treatment Form
Can be signed by:
- Adults age 18 and older, unless declared incapacitated by a court of law (i.e. have a legally appointed guardian).
- Minors age 13-17
- Parents of a minor child (age 17 or younger) – adolescents should sign their own pre-assessment paperwork forms
- Legal guardians
- Kinship Caregivers – family members of a child under the age of 13 who are providing care for the child in the absence of a parent or legal guardian. Parent/guardian is not available.
If the client is unable to sign for themselves (i.e. under 13, or an adult with a legal guardian) someone who can sign consent must attend the assessment with the client, or must sign the Consent for Treatment in advance).
Release of Information Form (ROI)
If you are not intending to release, exchange, or disclose your medical records to another individual, then do not complete the ROI at this time.
Who can sign an ROI? If the client is 13 or above, they must sign the ROI; if the client is 12 or younger, a parent/guardian must sign the ROI.
In order to best assist your treatment, it is strongly encouraged to complete the following ROIs:
- PCP
- If a minor client is age 13 or above, we strongly encourage an ROI for the parent or guardian.
- Other typical ROIs that we request from new clients include requests from School Counselors, Social Workers, other Medical Providers including recent hospitalizations, etc.
If this is a standalone request for information unrelated to submitting pre-assessment forms, please go to our Health Integration Management page.