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Green Hills with Blue Sky

Documents & Forms


 

**  With the increase of COVID-19 cases in the DC-Metro Area, and out of an abundance of caution and concern for the health of our clients, administrative staff and clinicians, we are closing all CCCC offices for on-site therapy effective immediately, while continuing Telehealth services.

We have been fortunate in that there have been no known cases of COVID-19 in the offices, and we hope that you and your families are also well. This closing will be in effect through the end of 2020, with further announcements coming in the beginning of 2021.

We will continue to follow in accordance with the local government guidelines as they evolve.  **

 

CRISIS RESOURCES

FOOD RESOURCES

**  FIRST RESPONDERS FRONT LINE SUPPORT GROUP  **

 


 

Telehealth Appointment Consent Form

Email to [email protected] with subject including " Telehealth "

Form must be signed in order to be accepted

 


 

If you are a New Client, please Read & Complete the following forms to the best of your abilitiy.

 

Bring the completed forms to your first counseling appointment, along with your Photo ID and Insurance Card. If you have any questions related to the paperwork, they will be addressed during the initial appointment.

 

If you do not have access to a printer, you may fill out the forms in office on the day of your appointment by arriving 15 minutes early before your scheduled appointment time.

 

NOTICE: 

Email is not a secure form of communication and we cannot guarantee confidentiality.

 

We advise against sending these completed forms with your protected health information (PHI) to us via email. Instead, we encourage you, if possible, to print out your respective form in order to read over and complete the form to bring with you to your first appointment.

 

 

If you have scheduled for Psychological Testing, you may print and complete out the respective form below to bring to your Evaluation Appointment:

 

 

Primary Care Physician release of information forms are included in the above packets. If you would like to coordinate care with, or release information to, a third party (e.g. an attorney, a family member,  a doctor other than your primary care physician), complete the respective form below and bring the completed form to your appointment to authorize release of your counseling information:

 

 


 

Note: To download Adobe Acrobat Reader for free, Click Here.

Again: Email is not a secure form of communication...we cannot guarantee confidentiality.

 


 

 

Caring, Committed Counseling in Your Community

Services for Individuals, Couples, Children & Families

 

 

 


 

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