Forms

Background Questionnaires and Consent Forms

Background questionnaires, consent forms and policy documents will be sent to clients at the time of assignment. Clients will be required to review, complete and sign these forms prior to their first session taking place.  If you wish to see any forms in advance of assignment, please contact our Intake Office at (703) 993-1370 or by email at psycclin@gmu.edu. 

Exchange of Information Form

The Exchange of Information Form is where you are able to provide permission for a GMU CPS provider to release/exchange information to or with another party. Due to client confidentiality, a signed copy of this form is required before we can exchange information about a client with another party.

If you are a young adult and you want your parent(s) involved in your treatment plan, including scheduling and billing, you must complete this form for us to be able to release/exchange information with them. Please note, unless noted on the form, it will expire one (1) year from the date you sign it.

Exchange of Information

Medical Record Request Form

To receive a copy of your medical record or request assistance in completing forms, please contact our Intake Office at (703) 993-1370 or email psycclin@gmu.edu. Fees vary depending on the type of request.  The Intake Office will determine the final fee for your request. 

Financial Forms

Clients who wish to apply for a fee reduction based on our sliding scale fee schedule will need to complete the Financial Aid Request Form and return the form with supporting documentation. See the Payment & Insurance section of our site for more details on applying for a fee reduction.


Financial Aid Request Form