Consent for Services
Name: Date of Birth:
Entry & Assessment
Treatment for Adolescents Age 14 or Older
Risks & Benefits
Release of Information
Legal Proceedings and Release of Records
Access to Records
Third Party Payer
Planned Health Care Decisions (for Adults or minors who are emancipated or married)
Declaration for Mental Health Treatment (for Adults)
A Declaration for Mental Health Treatment allows you to let health care professionals know your preferences regarding mental health care treatment if you are ever unable to make these decisions for yourself.
Advance Directive (for Adults)
The Advance Directive lets health care professionals know your preferences regarding life-sustaining help if you are near death and are unable to make these decisions for yourself. It also allows you to name a person with whom you have discussed your wishes to advocate for your choices.
Scheduling and Cancellations
CFD provides services to all individuals who are eligible regardless of race, ethnicity, gender, gender identity, gender expression, sexual orientation, religion, creed, national origin, age (except when program eligibility is restricted to children, adults, or older adults), familial status, marital status, source of income, and disability.
My signature affirms that I have read and understand this form and have had the opportunity to ask questions.
This document is being signed by: ClientPersonal Representative, see below
If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.
Full legal name of Personal Representative:
Relationship to client:
Definition of Personal Representative:For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent for Services
Agree & Sign