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The right care for your recovery
Finding the right mental health professional can help you take control of any issue in your life.
Location
22 Ball Street Irvington, NJ 07111
Phone
(973) 372-1095
Fax
(973) 372-1096
On-Call
(973) 704-2505
Intake
(973) 735-5463
Email
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Required fields are marked with an asterisk (*).
THE INFORMATION, WHICH MAY BE DISCLOSED (Circle/Check all that maybe released):
Presence in Treatment (Admission/Discharge Dates)
Medical History & Physical Examinations
Psychiatric/Psychological Evaluation
Physician Attestation Statement
Multi-disciplinary Treatment Team Progress Notes
Bio-Psycho-Social
Health Records, PPD results, MMR, HVC
Toxicology/Dosing history
Bloodwork Results
Others
THIS INFORMATION IS NEEDED FOR THE FOLLOWING PURPOSES: (Circle/Check all that apply)
To provide ongoing treatment/continuing care
To coordinate treatment efforts with my family/significant others/concerned persons
To coordinate vocational training with vocational training program officials
To enable Judge, Attorneys, Probation/Parole Officer, to support treatment goals
The duration of this authorization is until:
Six months from the date of consent.
One year from the date of this consent.
Others
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