Consumer Registration & Symptom Checklist Form 

Every new SummitStone Health Partners consumer must fill out both the registration and behavioral health symptom checklist forms.

Download Registration Form (Adult 18+)
Download Registration Form (Child 0-17)
Download Symptom Checklist (Adult 18+)
Download Symptom Checklist (Youth 12-17)
Download Symptom Checklist (Child 0-11)

Release of Information (ROI)

This form allows us to communicate with anyone (i.e. probation, DHS, your medical providers, family members, etc.) that you would like to have us coordinate treatment /communicate with.

Download (English)
Download (español )

ROI Request to Communicate Via Email

This form allows us to communicate via Email with anyone (i.e. probation, DHS, your medical providers, family members, etc.) that you would like to have us coordinate treatment /communicate with.

Download (English)
Download (español )

Disclosure Statement and Consent to Treat Form 

This form provides information about your rights as a client, your agreement to participate in treatment and/or permission for a minor child to be treated.

Download (English)
Download (español )

Joint Notices of Privacy Practices 

This notice tells you how health and drug and alcohol information about you may be used and disclosed and how you can get this information.

Download (English)
Download (español )

Request for Access to Protected Health Information

This form is required to be completed by the parent, guardian or legal custodian of a minor child.

Download (English)
Download (español )

Financial Agreement

This form provides information about our financial policies and payment expectations.

Download (English)
Download (español )

Informed Consent During COVID-19

This form provides information about our services during the COVID-19 health crisis.

Download (English)
Download (español )

Medical Decision Making Form 

This form is required to be completed by the parent, guardian or legal custodian of a minor child.

Download (English)
Download (español )

Interstate Compact Client Questionnaire

This form must be completed by all adult clients seeking admission to a program for any education or treatment.

Download (English)

Primary Care Referral Form

This form is for a primary care referral (psychiatric, addiction medicine, and clinical services).

Download (English)

TeleHealth Consent Forms

Forms to be completed to access SummitStone TeleHealth services.

Download (English)