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Center for Behavioral Health

UMSL | Center for Behavioral Health

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Forms

Center for Behavioral Health

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Forms

Please complete the following forms and bring them with you to your appointment:

St. Louis County Residents:

Privacy Notice (Please read this notice and sign "Acknowledgment of Privacy Practices")
Acknowledgment of Privacy Practices
CSF Evaluation Consent Form
Release of Information
Proof of St. Louis County Residence
St. Louis County Referral Form
Medical/Developmental History Form

St. Louis City Residents:

Privacy Notice (Please read this notice and sign "Acknowledgment of Privacy Practices")
Acknowledgment of Privacy Practices
SOC Evaluation Consent Form
MHB Evaluation Consent Form
Release of Information
Proof of St. Louis City Residence
St. Louis City Referral Form
Medical/Developmental History Form

Franklin County Residents:

In order to begin the referral process, click complete the referral to the Team of Concern.

St. Charles County Residents:

Privacy Notice (Please read this notice and sign "Acknowledgment of Privacy Practices")
Acknowledgment of Privacy Practices
CCRB Evaluation Consent Form
Release of Information
Proof of St. Charles County Residence
St. Charles County Referral Form
Medical/Developmental History Form

Jefferson County Residents:

Privacy Notice (Please read this notice and sign "Acknowledgment of Privacy Practices")
Acknowledgment of Privacy Practices
JMF Evaluation Consent Form
Release of Information
Proof of Jefferson County Residence
Jefferson County Referral Form
Medical/Developmental History Form

Completed forms may also be faxed to CBH at 314-516-5347.

If you have any questions about the documentation you should bring to your appointment, please contact us at 314-516-4357 (H.E.L.P.).

Call today to schedule an appointment:

314-516-4357
314-516-HELP

Call today to schedule an appointment:

314-516-4357
314-516-HELP