Here is the opening paperwork to receive services at Four County Mental Health Center. Please clearly print information on the forms and plan to come at least 20 minutes early to your appointment to complete the registration process. Thank you for choosing Four County Mental Health Center.
Patient Rights and Responsibilities
Review your rights and expectations as a patient.
AIMS Admission Form
Please make certain that all of the fields are properly checked or filled out.
Patient Information/Financial Agreement
All blanks should be completed. Whomever is responsible for any payment due needs to sign the bottom of the 2nd page. Biological/adoptive parent or legal guardian.
Permission for Initial Treatment and Assessment
If the patient is a child, the biological parent or legal guardian should be the one to sign and date the form.
RELEASE OF INFORMATION FORMS
There must be an expiration date for the release to be valid, which can be no later than one year from signature date.
Release of Information Form – Blank
REGISTRATION FOR CHILDREN IN FOSTER CARE
Send any history that is available for the therapist to read over. Notify the foster parents of any appointment times.
We need the following releases for all foster children
Primary Care Physician
Dept. of Children and Families (DCF)