Printable Forms
Most CCPH forms are completed electronically through the Patient Portal (umass.medicatconnect.com). If the portal is unavailable, or if you have been asked to complete a form outside the portal, you can download and print the forms below.
If you have questions about which form you need, contact us at (413) 545-2337, Monday through Friday, 8:30 a.m. to 4:30 p.m.
Authorizes CCPH to share information from your record with another person or provider of your choosing, such as a family member, outside therapist, or insurance company.
Explains how CCPH uses and protects your personal health information under HIPAA. Review this when you begin services.
Required for students under 18 receiving services at CCPH. A parent or legal guardian must sign before treatment begins.
Required if you plan to meet with your clinician via video or phone. Covers the benefits, risks, and limitations of telehealth services.
Confirms that you understand and agree to CCPH's treatment policies, including confidentiality, its limits, and your rights as a client. Complete this before or at your first appointment.
For external therapists referring a client to CCPH's psychiatry services. This form is completed by the referring clinician, not the student.