Connecticut Institute of Behavioral Health IncPrivate Office
CIBH
Achieving satisfaction and physical well being.
Practice Forms
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New Patient Paperwork Please complete these forms and bring them with you to your first appointment. You can email to cibh.zeina@gmail.com. Please arrive 15-20 minutes prior to your appointment time with your photo ID and a copy of your insurance card. |
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TelePsych Informed Consent If you are a client who is interested in TelePsych services, please complete this form and fax it (860) 326-5571 or email to cibh.zeina@gmail@.com. |
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New Insurance Change If you have new or updated insurance information, please complete this form with a copy of your insurance card. Email to cibh.zeina@gmail.com or fax @ 860-326-5571. You can call the office @ 860-326-5405. |
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Authorization to Release Health Information (ROI) Please complete this form if you would like CIBH to disclose your personal health information with anyone other than yourself or to obtain records from your previous providers. You can email to cibh.zeina@gmail.com or fax @ 860-326-5571. |
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