Forms,
Notices, and Brochures
*indicates
notice and forms required of new clients
(All non new client forms are explained in our Notice of
Privacy Practices which is available and listed below)
Access Request Form
Accounting Request Form
Advanced Directives (Forms, Information, and Instructions)
Advance Directive, Psychiatric Q & A
Amendment Request Form
Authorization for Release of Info. Form
Authorization Revocation Form
Client Brochure (Word version) single sided (PDF vers) 2 sided (Publisher vers) 2
Confidential Communication Request Form
*Collateral Consent Form
*Credit/Debit Cards Informed Consent
*Consent Form
*General Information Form
*Identity Verification Form Explained
*Insurance Release Form
*Notice of Privacy Practices
*Notice of Privacy Practices Receipt
Privacy Complaint Fact Sheet
Privacy Complaint Form
Restriction Request Form
UBH Wellness Assessment Forms, Adult
UBH Wellness Assessment Forms, Child/Adolescent
525 East 4500 South, Suite 125, Salt Lake City, Utah 84107-2995
801-268-1564
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© 2002-2013, Christian Counseling Centers of Utah, a dba of Shepherd's Staff Christian Counseling Center. All rights reserved.