Intake Forms
Registration & Symptom Checklist Form
Every new SummitStone Health Partners consumer must fill out both the registration and behavioral health symptom checklist forms.
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.
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.
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.
TeleHealth Consent Forms
Forms to be completed to access SummitStone TeleHealth services.
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.
Financial Agreement
This form provides information about our financial policies and payment expectations.
Informed Consent During COVID-19
This form provides information about our services during the COVID-19 health crisis.
Medical Decision Making Form
This form is required to be completed by the parent, guardian or legal custodian of a minor child.
Interstate Compact Client Questionnaire
This form must be completed by all adult clients seeking admission to a program for any education or treatment.
Primary Care Referral Form
This form is for a primary care referral (psychiatric, addiction medicine, and clinical services).
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.