CANA

Center for Africans Now in America, Inc.

Forms

 

We use these forms to register our clients for our program Please read, print, and complete required form (s) prior to your first appointment. If you are unable to complete the form(s), plan to arrive early to complete it in our office. The forms are listed below with descriptions.  Please click the download buttons below to download forms that best fit your needs.

 


Form 1: Referral Intake

Please complete this form if you are a third party - i.e. another agency referring a client to CANA. Fill out the form and bring it to us in our office. You can also fax it to CANA (952) 707-9684. 

 

Form 2: Children/Minors Treatment Consent

Please complete this form for children 0-18 years old. Fill out this form and fax it along with other required forms.  

 

Form 3: Adult Treatment Consent

If you are  above 18 years of age, please complete this form to register as a CANA client. This form must be completed before any treatment begins.

 

Form 4: HIPAA - Private Information Notice

This form is very important. This form authorizes your therapist to confer with your other providers about your care. The providers may include county social service agencies, schools, corrections agencies, physicians, other therapists, clergy, or community advocacy groups. Please print, read,  and document any questions you may have about this form. You can use an interpreter to clarify areas you do not understand. Bring this form along to your first session. Then, sign it at your first session after your questions have been answered. 

 

Form 5: Insurance Information

Please complete this form if  you wish your insurance company to be billed for the services CANA has rendered to you.

 

Form 6: Confidentiality Protection

This form provides CANA an opportunity to ensure you a complete confidentiality agreement when using your medical and personal records. By completing and signing this form, you have the right to approve or refuse the release of your medical records to anyone outside of CANA. However, there are certain restrictions: Read your HIPAA form.

 

Form 7: E-mail/Video/Audio Communication

Electronic communication can be insecure. Therefore, the privacy of your health information cannot be fully ensured when transmitted by e-mail. Please let us know whether to send your health information by e-mail or via regular mail.

 

Other Forms

This form is for children and youth with severe  emotional problems. CANA staff will provide one-on-one skills training to help improve symptomatic behavior.

 

 

 © 2017 CANA - Center for Africans Now in America, Inc.

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