Access Family Services

Initial Referral Form

    Name: (required)

    Email: (required)

    Address: (required)

    , ,

    Birthdate / Gender:

    / MaleFemale

    Insurance:

    Legal Guardian:(required)

    Referral Source / Phone Number:

    /

    Brief Description of why you are seeking services.

    Requested Services:

    Intensive In HomeFamily Centered TreatmentOutpatientFoster CareOther

    Preferred Language / Accommodations:

    /

    Select Your Preferred Location.(required)

    * Once you have submitted this form, one of our staff members will contact you within 24 business hours.

    HIPAA Compliance

    As a client of Access Family Services, a record of health information is made. In adhering to our Best Practices for HIPAA Compliance, we have made our HIPAA, Confidentiality & Privacy Practices document available for download.

    HIPAA, Confidentiality & Privacy Practices
    [Download]

    Client Rights Handbook

    As a service to Access Family Services clients,, we have made our Client Rights Handbook available for download.

    Client Rights Handbook
    [Download]

     

    Client Rights Handbook
    (En Español)
    [Download]