To Protect Your Safety and That Of Our Staff, Medical and Mental Health Services are Now Available Via Videoconference During Throughout the COVID-19 Crisis. Contact Your Provider to Schedule an Appointment.
Thank you for using Family Centers' Electronic Enrollment process. If you are interested in recieving medical, dental or outpatient mental health services, intake packets are avilable below. Electronic enrollment allows us to serve you better by expediting the intake process.
Medical/Dental Enrollment Forms
Click here for adult medical/dental services. En Espanol
Click here for child medical/dental services. En Espanol
Once completed, email forms or fax to 203-622-2951.
Outpatient Behavioral Health Enrollment Forms
Once completed, email forms or fax to 203-661-4370.
Consent Form Required for Telehealth Services
A consent form must be completed in order to receive telehealth services (treatment via telephone and/or video conference).
Click here to email medical/dental forms or fax to 203-622-2951.
Click here to email outpatient mental health forms or fax to 203-661-4370.
NOTE: For those interested in signing the telehealth consent form electronically, a digital ID must be created. To create a digital ID, follow the following steps:
- Click on the signature field
- Choose "Create New Digital ID"
- Save File to PC
- Enter Info: Name, Email, Password
- Place Signature
- Save File
- Attach File to Email and Send