Copy of Forms - Kolpia Counseling

New Clients

Release of Information
Release of Information to provide information to, receive information from, or collaborate with family members or other providers (such as physician, probation officer, MAT prescriber, etc). A separate ROI must be completed for each person/entity you wish for Kolpia to communicate with. Please read instructions carefully, every line requires INITIALS (check marks or Xs will render the ROI invalid).
ROI Insurance
Clients attending services with main focus on substance use treatment (including DUII). If using insurance as payment source, this is required for us to bill your insurance.

Brochure - Digital
Brochure - Folded
Release of Information
Release of Information to provide information to, receive information from, or collaborate with family members or other providers (such as physician, probation officer, MAT prescriber, etc). A separate ROI must be completed for each person/entity you wish for Kolpia to communicate with. Please read instructions carefully, every line requires INITIALS (check marks or Xs will render the ROI invalid).
ROI Insurance
Clients attending services with main focus on substance use treatment (including DUII). If using insurance as payment source, this is required for us to bill your insurance.

DUII Agreement
Clients completing a legal mandate after receiving a DUII
No ADES Agreement
Clients completing a legal mandate after receiving a DUII, and starting treatment prior to completing their evaluation with the ADSS at community justice
Release of Information
Release of Information to provide information to, receive information from, or collaborate with family members or other providers (such as physician, probation officer, MAT prescriber, etc). A separate ROI must be completed for each person/entity you wish for Kolpia to communicate with. Please read instructions carefully, every line requires INITIALS (check marks or Xs will render the ROI invalid).
ROI Insurance
Clients attending services with main focus on substance use treatment (including DUII). If using insurance as payment source, this is required for us to bill your insurance.