All forms are completed through our secure DocuSign system. Click on the form you need, fill it out online, and submit directly to Cornerstone. If you have any questions, our team is here to help.

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Release of Information (ROI) Forms

To provide the best support for children and families, Cornerstone may need to share information with trusted partners such as schools, healthcare providers, or other service agencies. A signed Release of Information (ROI) form gives us permission to do this on your behalf, ensuring that services are coordinated smoothly and confidentially.

➤ Minor Client ROI Form – For clients under 18 years old. This form must be signed by a parent or legal guardian to authorize Cornerstone to share information on behalf of the child.
Access Minor ROI Form

➤ Adult Client ROI Form – For clients 18 years and older signing for themselves. This form authorizes Cornerstone to share information with trusted partners to coordinate care.
Access Adult ROI Form

➤ Spouse/Relative/Legal Representative ROI Form – For a spouse, family member, or legal representative who has permission to act on the client’s behalf. This form authorizes Cornerstone to share information for coordinated support.
Access Spouse/Relative/Legal Representative ROI Form

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Billing Consent and Patient Insurance Information

This form provides your insurance details, authorizes Cornerstone to bill your insurer directly, and outlines your financial responsibility for co-pays and fees.

➤ Access Billing and Patient Insurance Information Form

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Treatment Agreement & Consent for Treatment

This agreement confirms consent to receive psychological services through Cornerstone Family Interventions, Inc. It explains confidentiality protections, client responsibilities, and the role of the therapist in the treatment process.

Choose the form that applies to you:

➤ Adult Client Form – For clients 18 years and older singing for themselves.
Access Adult Client Form

➤ Minor Client Form – For clients under 18 years old. This form must be signed by a parent or legal guardian on the client’s behalf.
Access Minor Client Form

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Need help completing a form?

We’re here for you. Please call us at (304) 369-5283 or email karaworkman@cfiwv.org for assistance.