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Remote Authorization

Hello and thank you for choosing Peninsula for your behavioral health services. Providing you with excellent services is our purpose and our passion. We are especially concerned about the health risks posed by the COVID-19 virus and to lessen that risk we have developed a way of serving you in your own home. We can best do this through the internet. If you don’t have access to the internet we can also help you using the telephone.

To start services with Peninsula you need to read the two documents on this webpage. These documents describe the agreements that we have with all of our patients. After you have read the documents, please answer the questions on this form and complete the form provided. When you complete the form it will automatically be sent to a nurse who will call you to start your Behavioral Health services.

Notice of Privacy Practices

Consent to Treat- English

Consent to Treat – Spanish

I certify that I have read and understand the Peninsula Outpatient Centers Consent and Memorandum of Agreement. I certify that I have the legal authority to consent to this document for myself or on the behalf of the patient.  I understand that by answering the questions below, I hereby agree to the terms of this document.

Consent to Treat

  • Month/Date/Year
  • Hour:Minute AM/PM
  • Please type your name here signifying all of the information you have provided is correct.