2024 Marketing Use and Disclosure Form
Please complete this form for release of photos, videos, testimonials etc. for media use.
Forms
Download & fill out
After completing applicable forms, please send to email@childandfamilydevelopment.com. You can also fax or mail the forms.
Encrypted Email Instructions
With detailed instructions and screenshots for your reference when receiving and opening encrypted emails from us. It is not necessary for you to print or sign this form.
Client Access To Medical Record Form
Please complete this form to request additional copies of clinical documentation. It is not necessary for your first appointment.
Authorization for Release of Information Form
Please complete form to authorize release of information or medical records to designated individuals, providers, or entities.
Request For Unencrypted Email Form
On occasion, a client may request to receive information by unsecured and unencrypted email method. Communication is intended for brief exchange of information with limited disclosure of PHI. Complete this form to request this method. It is not necessary for your first appointment.