Forms

Background Questionnaires

Clinicians often use these forms in the first session to gather some initial information. It is helpful if you can bring the form completed to your first session.

Child History & Background Questionnaire

Consent Forms

Our consent forms provide an overview of treatment and assessment services, as well as GMU CPS policies. Reviewing these forms will give you an idea of what you are agreeing to when you decide to seek services here.  It is a great idea to review these documents before your first session. 

Electronic Communications and Social Media Policy

Weapons and Emergency Contacts

Consent to Treatment 

Telehealth Consent Form

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, print out and complete our request form below and mail, scan/email, or fax it to us. For your convenience, our contact information is included on the form.

 Medical Record Request Form

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

*To pay by Credit Card, click here.