SELF-PAY APPOINTMENT DOCUMENTS
Thank you for scheduling with CCBH
Please complete the forms that apply to the patient’s age and appointment type, along with any forms specifically requested by the office.
The forms below open in Google Forms in a new tab. If you are unsure which forms to complete, call the West Hartford office at (959) 240-0250 before submitting them.
Office forms for adults and children
Complete these shared office forms for adult or child appointments when instructed by the practice.
Adult appointment forms
Use these forms for an adult patient. Complete screening questionnaires only when requested by the clinician or office.
Child and adolescent appointment forms
Use the demographic and intake forms for a child or adolescent patient. Complete age- or condition-specific questionnaires only when the clinician or office asks for them.
For children ages 18 months–5 years: call the office for the current age-specific packet. The former site supplied this as a PDF rather than a Google Form, so it is not included here until the practice approves the current version.
Before you submit
- Confirm that the form opens under the practice-approved Google account and that its title matches the form you intended to complete.
- Do not email copies of completed forms or include passwords, payment-card numbers, or unrelated medical records.
- Completing a form does not establish a clinician-patient relationship, confirm an appointment, or replace a clinical evaluation.
This page and the linked forms are not monitored for emergencies. Call 911 for immediate danger, call or text 988 for crisis support, or dial 211 in Connecticut for local health and mobile-crisis connections.