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Forms Disclaimer:
THE CHESTNUT RIDGE COUNSELING SERVICES REFERRAL AND ADMISSION FOR SERVICES REALTED FORMS ARE USED TO BEGIN ARRANGING FOR CARE. YOU ARE SUBMITTING FORMS AND INDICATING TO CHESTNUT RIDGE COUNSELING SERVICES THAT IT IS THE APPROPRIATE. TO EXPIDITE CONFIDENTIAL CONTACT WITH US FOR SERVICE YOU ARE REQUESTING. THE INFORMATION YOU PROVIDE WILL BE KEPT PRIVATE IN ACCORDANCE WITH CHESTNUT RIDGE COUNSELING SERVICES CONFIDENTIALITY POLICIES, HIPAA GUIDELINES AND MAY BE SEEN BY A LIMITED NUMBER OF AUTHORIZED INDIVIDUALS AS NECESSARY. IF YOU NEED TO CHANGE THIS INFORMATION, PLEASE CONTACT THE PROGRAM USING THE CONTACT INFORMATION PAGE UNDER EARCH SERVICE PROVIDER PROGRAM ON THIS WEB SITE. WE MAY CONTACT YOU IF WE NEED TO VERIFY OR OBTAIN FURTHER INFORMATION. YOU SHOULD UNDERSTAND THAT THIS REFERRAL FORM DOES NOT ESTABLISH A DOCTOR-PATIENT RELATIONSHIP; YOU MAY BECOME A PATIENT ONCE YOU COME TO CHESTNUT RIDGE COUNSELING SERVICES FOR TREATMENT. AT THAT POINT, ANY ELECTRONIC FORMS PRINTED AND SUBMITTED VIA FAX, POSTAL MAIL OR PERSONALLY SUBMITTED WILL BECOME PART OF YOUR MEDICAL RECORD.
CHILDREN UNDER EIGHTEEN (18) MAY NOT SUBMIT THIS FORM VIA THE INTERNET. ONLY PARENTS OR LEGAL CUSTODIANS OR GUARDINS MAY SUBMIT THIS INFORMATION
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