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Youth and Family Forms

PerformCare uses forms for a variety of purposes. Some are required by law in order to ensure we are protecting the privacy of your treatment information. Some are designed to make it easier for you to request something from us (such as a record release). Forms that are frequently accessed by youth and families are made available here with descriptions as appropriate.

To request the release of a child’s protected health information (either a physical or verbal release) from PerformCare, please use the form linked below. If a parent is requesting that the information be released directly to them, the parent should enter their own information in the Other section at the bottom of Part 2 of the form.

Please note that this form should be completed in its entirety. Incomplete or incorrect forms may delay the fulfillment of the request. Completed forms should be faxed to PerformCare at 1-877-736-9166.

Intellectual/developmental disability services

Substance use treatment services

In order to register a youth who needs substance use treatment or authorize care, the youth must sign this consent form. All associated service providers must be included on the form. Please have both the consent and the explanation available for the youth to view. If you are filling out the form without the provider present, please call PerformCare to ensure you have included all appropriate service providers.

For the interim, please utilize the standard PerformCare consent to release protected health information (PDF) document to obtain youth consent to release records to PerformCare and other agencies who may need to view the youth's record, including all substance use treatment agencies for the level of care being requested.