Thank you for contacting our program for services. This form is to be completed by the person 18 years or older, who is scheduled for an appointment with our program. If the person scheduled is under 18 years old, this form must be completed and signed by the parent or legal guardian of the minor.
Please complete, sign and submit the form below prior to your scheduled appointment. If you have any questions or concerns, please reach out to C&FS EAP at 716-681-4300. This form may not be reviewed for up to 2 business days. If this is an emergency, please contact emergency services by dialing 911. If you are seeking mental health support and would like to speak to a counselor immediately, please call 716-681-4300 and press option 2, C&FS EAP is available.
You may review C&FS information and HIPAA Policy here.