Adult Intake Paperwork

Lakes Region Mental Health Center > For Our Patients > Adult Intake Paperwork

Click the buttons below to review and sign each electronic document.

Application & Consent for Services
Medical Screening
Release of Information
Authorized Representative
Patient Rights & Responsibilities
Notice of Privacy Practices
Contact & Insurance Information

Lakes Region Mental Health Center provides comprehensive, integrated mental health treatment for people living with – and recovering from – mental illness and/or emotional distress.

Emergency: 988 or 833-710-6477
General: 603-524-1100
Fax: 603-528-0760

Medical Record Fax: 603-527-8104

FIND US AT:
40 Beacon St. E, Laconia, NH
81 Highland St., Plymouth, NH

Staff Portal
Board Portal
Join our Email Newsletter List

Sign up to receive Newsletters, company updates and more! Click the link below:

Latest Newsletter
Join our Email List

© (2023) Lakes Region Mental Health Center.

2024 LRMHC does not discriminate on the basis of race, color, national origin (including primary language), disability, age, religion, or sex (including pregnancy, sexual orientation, and gender identity), in accordance with the Title VI Act of the Civil Rights Act of 1964 and the Americans with Disabilities Act of 1990. LRMHC will make reasonable modifications to its policies and procedures upon request. LMRHC provides free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, written information in other formats (large print, audio, accessible electronic formats, other formats), language services to people whose primary language is not English. If you want to request modifications or request any of these services, contact us at the number above.