Client Forms

As a client of Canvas Health, you are entitled to certain rights regarding your care and information. Please view the following videos for more information.

• How to Request Amendments
• Your Health Information Rights
• How to Access your Health Information
• Canvas Health Patient Bill of Rights

• Release of Information Form
• Client Acknowledgement Form
• Telehealth Acknowledgement Form 
• Unsecure Data Consent Form
• Telehealth Consent Agreement
• E-Signature Consent Agreement 
• Customer Satisfaction Survey

• Adult Day Treatment/Group Therapy Referral Form
• Children’s Case Management Referral Form
• Children’s Therapeutic & Support Services Referral Form
• Circle of Security Referral Form
• Early Childhood Behavior Assistance Referral Form
• Family Treatment Program Referral Form – Washington County Only 
• In-Home Skills Referral Form – Washington County Only
• Partnering for Jobs Referral Form
• Psychological Services Request for Assessment Form
• Therapeutic Learning Center (TLC) Referral Form
• Therapeutic Education Collective (TEC) Referral Form

Please print, complete, and bring these materials to your appointment

• Client Acknowledgement Form
• Consent for the Release of Private Information Form
• Client Information Packet
• Telehealth Acknowledgement Form

Please print, complete, and bring these materials to your appointment

• Client Acknowledgement Form
• Consent for the Release of Private Information Form
• Client Information Packet
• Telehealth Acknowledgement Form

Please print, complete, and bring these materials to your appointment.

• Client Acknowledgement Form
• Consent for the Release of Private Information Form
• Client Information Packet
• Telehealth Acknowledgement Form

• Client Information Packet – Spanish 
• Informed Consent to Treatment – Spanish 
• Client Acknowledgement – Spanish
• Nondiscrimination Notice – Spanish
• Patient Bill of Rights – Spanish
• Reminder Information – Spanish