Client Forms

Client Forms

Our forms are available online for your convenience!  We recommend you use a phone or tablet, as it will be easier to provide pictures of photo ID, insurance cards, etc.

New Clients:  Please fill out the New Client Intake and Credit/Debit Card on File Authorization forms below.  There are different forms for adults and minor children.

Current Clients:  Forms are available for you to update your Credit/Debit Card on File, and Insurance Information.

All Clients:  If you would like us to collaborate or share information with another provider or family member, please fill out an Authorization for Release of Information form.

 

New Clients – Adults

New Client Intake Form (Adults) – must be completed by the client

Payment Authorization – Credit/Debit Card on File – must be completed by the cardholder

Authorization for Release of Information (Adults) – optional, must be completed by the client if you would like us to collaborate or share information with another provider or family member

 

New Clients – Minor Children

New Client Intake Form (Minor Child) – must be completed by the responsible party (a parent or guardian)

Payment Authorization – Credit/Debit Card on File – must be completed by the cardholder

Authorization for Release of Information (Minor Child) – optional, must be completed by the responsible party (a parent or guardian) if you would like us to collaborate or share information with another provider or family member

 

Current Clients

Payment Authorization – Credit/Debit Card on File – to add or replace an existing credit/debit card on file, must be completed by the cardholder

Update Insurance Information – must be completed and signed by the client or responsible party (a parent or guardian)

Authorization for Release of Information (Adults) – must be completed and signed by the client

Authorization for Release of Information (Minor Child) – must be completed and signed by the responsible party (a parent or guardian)

 

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38807 Ann Arbor Rd Ste 9
Livonia, MI 48150

info@collaborativehealthcenter.com
(734) 772-0148