(801) 358-4463 chcs@clearhorizons.org

Forms

 

Select the applicable section to see available forms for download.

Adult Forms

Client Information: Page 1 – Please fill out the section “Patients 18 or Older Only.” If using private insurance as part of your payment, please fill out all necessary information to bill insurance company correctly.   Page 2 – Please sign all patient signature lines.
Client Information Form

Release of Information: Please sign any applicable forms.
Release of Information FormRelease of Information – DCFS Form

Other Forms:
Client Rights and Responsibilities FormNotice of Privacy Policies

Caseworkers

Client Information:  Page 1 – Please fill out parent / foster parent information, your caseworker information and the children information section for each child participating in the foster care.  *Only one child per information sheet (i.e. if 2 children involved with the same foster care parents, then 2 client information sheets will be filled out).  Page 2 – Please sign all legal guardian signature lines except credit & finance charge agreement.
Client Information Form

Other Forms:
Release of Information FormRelease of Information – DCFS FormClient Rights and Responsibilities FormNotice of Privacy Policies

Foster Parents

Client Information:  Page 1 – Please fill out parent / foster parent information, the caseworker information (if known) and the children information for each child participating in your foster care.  *Only one child per information sheet (i.e. if 2 children involved with the same foster care parents, then 2 client information sheets will be filled out).  Page 2 – Please sign only the two (2) foster parent signature lines.
Client Information Form

Other Forms:
Client Rights and Responsibilities FormNotice of Privacy Policies

Parent or Guardian

Client Information:   Page 1 – Please fill out parent / foster parent information and your child(ren) information.  If using private insurance as part of your payment, please fill out all necessary information to bill insurance company correctly.   Page 2 – Please sign all patient signature lines.
Client Information Form

Release of Information: Please sign any applicable forms.
Release of Information FormRelease of Information – DCFS Form

Other Forms:
Client Rights and Responsibilities FormNotice of Privacy Policies

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