Intake Form
Complete your new patient intake packet before your first visit. Four short forms, signed together as one packet.
- About 20 minutesAll four forms, start to finish.
- Save and returnYou do not have to finish in one sitting.
- Paper copiesAvailable on request, or fill them in with us.
- Help in your languageEspañol and Kreyòl Ayisyen. TTY/Relay: 7-1-1.
What you will complete
Four forms, completed together as one packet.
Form A: Authorization for Release of Medical Records
Authorizes records to be sent to or requested from other providers, with separate protections for HIV/AIDS, substance use, mental health, and STI records as required by law.
Form B: Patient Registration & Financial
Contact information, insurance, and sliding-fee eligibility.
Form C: Consents & Agreements
Consent to treatment and related program agreements.
Form D: Clinical Assessment & Testing
Initial clinical intake and testing consent.
Complete the packet online
All four forms are signed together in one DocuSign session. Set aside about 20 minutes. You can save and return to it later.
Not live yet The online packet is being set up. Please use one of the options on the right in the meantime.
Start your intake today
Both of these work right now, and either way our team completes the packet with you.
Need a paper copy or the forms in another language? Call the number above. TTY/Relay: 7-1-1.