Department of Psychiatry

Penn Behavioral Health

Intake and Consent Forms

Intake

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.

Consent

Client Rights and Responsibilities

HIPAA Acknowledgement

Custody 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.


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