Department of Psychiatry

Penn Behavioral Health

Intake and Consent Forms


MFC Intake - Adult Veteran

MFC Intake - Adult Family Member

MFC Intake - Child

*For families, couples, partners, and spouses, each client should fill out an individual intake form.


Client Rights and Responsibilities

HIPAA Acknowledgement

Authorization for Disclosure of Health Information 
Signed Authorization for Disclosure of Health Information requests can be faxed (215-898-0509), mailed (3535 Market Street, Suite 670, Philadelphia, PA 19104), or completed in the clinic. Third party requestors must submit a valid release inclusive of service dates. There is no charge for medical records at this time.

Statement of Client's Rights
View our Penn Medicine Client Bill of Rights, available in various languages.

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