Forms

Directions: Click the link to open the file. Print when finished; this website will not save your completed form(s).

New Client Forms

New Client Paperwork–The CBPS New Client Packet at this link provides information regarding our services, rates, and policies and is required for all new clients. You can fill it out and sign online (no paper required). Note that parents of minor clients are also required to provide contact information for the child’s other parent or legal guardian. Please note that the form may not auto-save, so use the save icon to avoid losing your work.

Optional Forms

Adult Screening Form–For adults, the client may print and complete the Adult Screening Form and bring it to the first appointment.

Child Screening Form and Child Background Form–For children aged 6 to 17, parents may print and complete these forms and bring them to the first appointment.

Other Forms

Authorization to Release Information–To authorize the release of information to or from CBPS, a client or guardian may complete, print, sign, and return this form.

CBPS Credit Card Agreement–To authorize CBPS to charge a credit card each time a balance is due on the account, the cardholder may complete, print, sign, and return this form.

CBPS Guarantor Fee Agreement–If someone who did not sign the original Fee Agreement wishes to take responsibility for payment, that person may complete, print, sign, and return this form.

CBPS No Surprises Act Notice–The CBPS No Surprises Act Notice pertains to uninsured clients or clients not using insurance to pay for services at CBPS.

CBPS Discount Application for Families–For clients or families unable to pay our customary fees, an adult family member may use this form to apply for a discount based upon income and family size. (Approved discounts are applied to future services only.)

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