{"id":986,"date":"2019-04-19T19:10:27","date_gmt":"2019-04-19T19:10:27","guid":{"rendered":"http:\/\/chenaltherapy.com\/?page_id=986"},"modified":"2025-11-03T22:49:43","modified_gmt":"2025-11-03T22:49:43","slug":"forms","status":"publish","type":"page","link":"https:\/\/chenaltherapy.com\/es\/forms\/","title":{"rendered":"formularios"},"content":{"rendered":"

[et_pb_section fb_built=”1″ fullwidth=”on” module_id=”sticky” _builder_version=”4.16″ z_index=”147″ da_disable_devices=”off|off|off” box_shadow_style=”preset1″ saved_tabs=”all” global_colors_info=”{}” da_is_popup=”off” da_exit_intent=”off” da_has_close=”on” da_alt_close=”off” da_dark_close=”off” da_not_modal=”on” da_is_singular=”off” da_with_loader=”off” da_has_shadow=”on”][et_pb_fullwidth_menu menu_id=”2″ fullwidth_menu=”off” active_link_color=”#d5e3ee” mobile_menu_bg_color=”#505b6f” mobile_menu_text_color=”#ffffff” module_id=”sticky” _builder_version=”4.16″ menu_font=”||||||||” menu_font_size=”19px” background_color=”#324058″ text_orientation=”right” background_layout=”dark” module_alignment=”right” menu_text_shadow_style=”preset3″ global_colors_info=”{}”][\/et_pb_fullwidth_menu][\/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.16″ background_image=”https:\/\/chenaltherapy.com\/wp-content\/uploads\/2019\/04\/973e2f80.png” background_size=”initial” background_repeat=”repeat” top_divider_color=”rgba(85,93,112,0.95)” top_divider_height=”38px” top_divider_flip=”vertical” bottom_divider_height=”60px” bottom_divider_flip=”horizontal” animation_style=”slide” animation_direction=”top” animation_intensity_slide=”25%” da_disable_devices=”off|off|off” global_colors_info=”{}” da_is_popup=”off” da_exit_intent=”off” da_has_close=”on” da_alt_close=”off” da_dark_close=”off” da_not_modal=”on” da_is_singular=”off” da_with_loader=”off” da_has_shadow=”on”][et_pb_row column_structure=”3_5,2_5″ _builder_version=”4.16″ global_colors_info=”{}”][et_pb_column type=”3_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.16″ text_font=”|300|||||||” text_font_size=”60px” text_line_height=”1em” header_font=”Quicksand|300|||||||” header_font_size=”60px” header_2_font=”||on||||||” header_2_font_size=”19px” global_colors_info=”{}”]<\/p>\n

Release of Records and Documentation<\/span><\/h2>\n

Forms<\/h1>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=”2_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.16″ background_image=”https:\/\/chenaltherapy.com\/wp-content\/uploads\/2019\/04\/Curves-2.png” background_size=”initial” background_position=”bottom_left” custom_padding=”98px||98px||true|” da_disable_devices=”off|off|off” global_colors_info=”{}” da_is_popup=”off” da_exit_intent=”off” da_has_close=”on” da_alt_close=”off” da_dark_close=”off” da_not_modal=”on” da_is_singular=”off” da_with_loader=”off” da_has_shadow=”on”][et_pb_row column_structure=”3_5,2_5″ _builder_version=”4.27.4″ custom_margin=”|auto|-34px|auto||” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″][et_pb_column type=”3_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.16″ global_colors_info=”{}”]<\/p>\n

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Important<\/em>:<\/span>\u00a0\u00a0<\/span><\/span><\/h3>\n

All requests for release of\u00a0information<\/span>\u00a0must be notarized\u00a0and\u00a0we must have the\u00a0<\/span>ORIGINAL\u00a0notarized copy on file. (Many banks will notarize documents\u00a0for their clients at no charge.) Remember, do\u00a0not to sign the form until you are in the presence of the notary\u00a0-OR- the if the client does not sign it in front of\u00a0<\/span>the a<\/span>\u00a0staff member, the ROI<\/span>\u00a0is required to be notarized, per our CFT policy and as stated in our Informed Consent.<\/span><\/span><\/p>\n

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[\/et_pb_text][\/et_pb_column][et_pb_column type=”2_5″ _builder_version=”4.27.4″ custom_padding=”|||” hover_enabled=”0″ global_colors_info=”{}” custom_padding__hover=”|||” background_enable_color=”off” sticky_enabled=”0″][et_pb_blurb title=”ROI to Release CFT Records” url_new_window=”on” use_icon=”on” font_icon=”l||divi||400″ icon_color=”#ffffff” icon_placement=”left” image_icon_width=”68px” _builder_version=”4.27.4″ header_font=”||on||||||” text_orientation=”center” background_layout=”dark” custom_padding=”30px|30px|30px|30px” link_option_url=”https:\/\/intakeq.com\/c\/ktPO4u” link_option_url_new_window=”on” hover_enabled=”0″ icon_font_size=”68px” global_colors_info=”{}” custom_margin=”||||false|false” sticky_enabled=”0″ background_color=”#324058″]<\/p>\n

View Here<\/p>\n

[\/et_pb_blurb][et_pb_blurb title=”ROI to Request Records Sent to CFT” url_new_window=”on” use_icon=”on” font_icon=”l||divi||400″ icon_color=”#ffffff” icon_placement=”left” image_icon_width=”68px” _builder_version=”4.27.4″ header_font=”||on||||||” text_orientation=”center” background_layout=”dark” custom_padding=”30px|30px|30px|30px” link_option_url=”https:\/\/intakeq.com\/c\/Dmrr1X” link_option_url_new_window=”on” hover_enabled=”0″ icon_font_size=”68px” global_colors_info=”{}” background_color=”#324058″ sticky_enabled=”0″]<\/p>\n

View Here<\/p>\n

[\/et_pb_blurb][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.16″ global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.16″ global_colors_info=”{}”]<\/p>\n

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Chenal Family Therapy, PLC has a very strict records release policy, even if documentation or records are being released directly to you the client. In\u00a0ALL\u00a0cases, written permission is required to release any written documentation of any kind or to communicate with any parties besides those under our care. Further, the identities of all parties authorizing release must be verified by one of our staff using your government-issued photo identification or by providing us with a notarized copy of our release form.<\/span><\/p>\n

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The one standing exception will be psychological testing clients, who will sign an ROI as part of their intake paperwork. For security purposes, we will require\u00a0making a copy the client\u2019s\u00a0photo ID for identity verification.<\/span><\/span><\/p>\n

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As a reminder, in accordance with standards set by the Arkansas Medical Board, we will be charging the following for all records releases:<\/p>\n

– $15.00 labor fee on all records
– $0.50 per page for first 25 pages, then $0.25 thereafter
– All postage related to the notes
– $50 rush fee for anyone wanting less than our standard 5-10 business days minimum<\/p>\n

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If you have questions, please email\u00a0Records@Chenaltherapy.com<\/a>\u00a0.\u00a0<\/span><\/span><\/p>\n<\/div>\n

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[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=”1″ module_id=”stop” _builder_version=”4.27.4″ background_color=”rgba(243,243,243,0.43)” min_height=”691.2px” custom_padding=”14px|0px|0px|0px|false|false” custom_css_main_element=”index:99″ da_disable_devices=”off|off|off” global_module=”47″ saved_tabs=”all” global_colors_info=”{}” da_is_popup=”off” da_exit_intent=”off” da_has_close=”on” da_alt_close=”off” da_dark_close=”off” da_not_modal=”on” da_is_singular=”off” da_with_loader=”off” da_has_shadow=”on”][et_pb_row column_structure=”1_5,1_5,1_5,1_5,1_5″ _builder_version=”4.16″ custom_margin=”-130px||” global_colors_info=”{}”][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_image src=”https:\/\/chenaltherapy.com\/wp-content\/uploads\/2019\/04\/cropped-CFT-Icon.png” title_text=”cropped-CFT-Icon.png” _builder_version=”4.27.0″ _module_preset=”default” width_tablet=”50%” width_phone=”” width_last_edited=”on|phone” module_alignment_tablet=”center” module_alignment_phone=”” module_alignment_last_edited=”on|tablet” global_colors_info=”{}”][\/et_pb_image][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=”1_5,1_5,1_5,1_5,1_5″ _builder_version=”4.27.0″ custom_margin=”-130px||” global_colors_info=”{}”][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=”1_5,1_5,1_5,1_5,1_5″ custom_padding_last_edited=”on|phone” _builder_version=”4.27.0″ custom_padding=”0px|0px|0px|0px|true|false” custom_padding_tablet=”50px||||false|false” custom_padding_phone=”” global_colors_info=”{}”][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.16″ text_font=”||||||||” header_font=”||||||||” header_font_size=”18px” header_letter_spacing=”2px” header_2_font=”||||||||” global_colors_info=”{}”]<\/p>\n

Contact Us<\/i><\/b><\/span><\/h4>\n

[\/et_pb_text][et_pb_text _builder_version=”4.27.4″ text_font=”||||||||” text_font_size=”12px” text_line_height=”1em” global_colors_info=”{}”]<\/p>\n

(501) 781-2230<\/a><\/p>\n

(870) 340-2636<\/a><\/p>\n

(479) 595-0333<\/a><\/p>\n

Toll-free: 1 (844) 755-0530<\/a><\/p>\n

Fax: (888) 816-7916<\/p>\n

Info@ChenalTherapy.com<\/a><\/p>\n

[\/et_pb_text][et_pb_image src=”https:\/\/chenaltherapy.com\/wp-content\/uploads\/2019\/04\/psychology-today-1.png” alt=”Verified by Psychology Today” url_new_window=”on” admin_label=”Image” _builder_version=”4.16″ width=”81%” width_tablet=”” width_phone=”35%” width_last_edited=”on|phone” module_alignment=”left” custom_margin=”-15px||” box_shadow_style=”preset1″ box_shadow_color=”rgba(0,0,0,0.01)” always_center_on_mobile=”off” global_colors_info=”{}”][\/et_pb_image][et_pb_image src=”https:\/\/chenaltherapy.com\/wp-content\/uploads\/2020\/12\/CARF_GoldSeal.png” alt=”Verified by Psychology Today” title_text=”CARF_GoldSeal” url_new_window=”on” align=”center” admin_label=”Image” _builder_version=”4.16″ width=”81%” width_tablet=”” width_phone=”35%” width_last_edited=”on|phone” module_alignment=”left” custom_margin=”-15px||” box_shadow_style=”preset1″ box_shadow_color=”rgba(0,0,0,0.01)” always_center_on_mobile=”off” global_colors_info=”{}”][\/et_pb_image][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.16″ text_font=”||||||||” header_font=”||||||||” header_font_size=”18px” header_letter_spacing=”2px” header_2_font=”||||||||” global_colors_info=”{}”]<\/p>\n

Locations<\/i><\/b><\/span><\/h4>\n

[\/et_pb_text][et_pb_text _builder_version=”4.27.4″ text_font=”||||||||” text_font_size=”12px” text_line_height=”1em” custom_margin=”-10px|||-25px” global_colors_info=”{}”]<\/p>\n\n\n\n
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Bella Vista<\/a><\/p>\n

Berryville<\/a><\/p>\n

Bryant – East<\/a><\/p>\n

Bryant – West<\/a><\/p>\n

Cabot<\/a><\/p>\n

Clinton<\/a><\/p>\n

Conway<\/a><\/p>\n

El Dorado<\/a><\/p>\n

Fayetteville<\/a><\/p>\n

Forrest City<\/a><\/p>\n

Fort Smith<\/a><\/p>\n<\/td>\n

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Harrison<\/a><\/p>\n

Hot Springs<\/a><\/p>\n

Jonesboro<\/a><\/p>\n

Magnolia<\/a><\/p>\n

Mountain Home<\/a><\/p>\n

North Little Rock<\/a><\/p>\n

Rogers<\/a><\/p>\n

Russellville<\/a><\/p>\n

Searcy<\/a><\/p>\n

Texarkana, AR<\/a><\/p>\n

West Little Rock<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.16″ text_font=”||||||||” header_font=”||||||||” header_font_size=”18px” header_letter_spacing=”2px” header_2_font=”||||||||” global_colors_info=”{}”]<\/p>\n

Services<\/i><\/b><\/span><\/h4>\n

[\/et_pb_text][et_pb_text _builder_version=”4.16″ text_font=”||||||||” text_font_size=”12px” text_line_height=”1em” global_colors_info=”{}”]<\/p>\n

Therapy<\/a><\/p>\n

Anger Management<\/a><\/p>\n

Testing<\/a><\/p>\n

Intensive<\/a><\/p>\n

Medication Management<\/a><\/p>\n

Online Counseling<\/a><\/p>\n

Low-Cost Options<\/a><\/p>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.16″ text_font=”||||||||” header_font=”||||||||” header_font_size=”18px” header_letter_spacing=”2px” header_2_font=”||||||||” global_colors_info=”{}”]<\/p>\n

Quick Navigation<\/i><\/b><\/span><\/h4>\n

[\/et_pb_text][et_pb_text _builder_version=”4.18.0″ text_font=”||||||||” text_font_size=”12px” text_line_height=”1em” global_colors_info=”{}”]<\/p>\n

Online Payment<\/a><\/p>\n

Schedule Appointment<\/a><\/p>\n

Careers<\/a><\/p>\n

Resources<\/a><\/p>\n

Referrals<\/a><\/p>\n

Trainings<\/a><\/p>\n

[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=”1_4,1_4,1_4,1_4″ _builder_version=”4.16″ custom_padding=”0|0px|0|0px|false|false” global_colors_info=”{}”][et_pb_column type=”1_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][et_pb_column type=”1_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_image src=”https:\/\/chenaltherapy.com\/wp-content\/uploads\/2023\/04\/SPP-Logo.png” alt=”Verified by Psychology Today” title_text=”SPP Logo” url_new_window=”on” align=”center” admin_label=”Image” _builder_version=”4.18.0″ width=”81%” width_tablet=”” width_phone=”35%” width_last_edited=”on|phone” module_alignment=”left” custom_margin=”-15px||” box_shadow_style=”preset1″ box_shadow_color=”rgba(0,0,0,0.01)” always_center_on_mobile=”off” global_colors_info=”{}”][\/et_pb_image][\/et_pb_column][et_pb_column type=”1_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_image src=”https:\/\/chenaltherapy.com\/wp-content\/uploads\/2023\/04\/ACEP-Logo.png” alt=”Verified by Psychology Today” title_text=”ACEP Logo” url_new_window=”on” align=”center” admin_label=”Image” _builder_version=”4.18.0″ width=”81%” width_tablet=”” width_phone=”35%” width_last_edited=”on|phone” module_alignment=”left” custom_margin=”-15px||” box_shadow_style=”preset1″ box_shadow_color=”rgba(0,0,0,0.01)” always_center_on_mobile=”off” global_colors_info=”{}”][\/et_pb_image][\/et_pb_column][et_pb_column type=”1_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.18.0″ module_alignment=”center” custom_padding=”||||false|false” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.18.0″ text_font=”||||||||” text_font_size=”12px” text_line_height=”1em” global_colors_info=”{}”]<\/p>\n

SPP is a subset of Chenal Family Therapy, PLC, ACEP Provider Number: 7233<\/i><\/p>\n

[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"

Release of Records and Documentation Forms Important:\u00a0\u00a0 All requests for release of\u00a0information\u00a0must be notarized\u00a0and\u00a0we must have the\u00a0ORIGINAL\u00a0notarized copy on file. (Many banks will notarize documents\u00a0for their clients at no charge.) Remember, do\u00a0not to sign the form until you are in the presence of the notary\u00a0-OR- the if the client does not sign it in front […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-986","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/chenaltherapy.com\/es\/wp-json\/wp\/v2\/pages\/986","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/chenaltherapy.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/chenaltherapy.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/chenaltherapy.com\/es\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/chenaltherapy.com\/es\/wp-json\/wp\/v2\/comments?post=986"}],"version-history":[{"count":0,"href":"https:\/\/chenaltherapy.com\/es\/wp-json\/wp\/v2\/pages\/986\/revisions"}],"wp:attachment":[{"href":"https:\/\/chenaltherapy.com\/es\/wp-json\/wp\/v2\/media?parent=986"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}