Patient Forms

Below are the forms and links we use to help you get your medical marijuana card in Connecticut. As long as you are a CT resident, not an inmate and have a medical condition start at Step 1.

Step 1:

Request an appointment – Here is where it all begins.

Step 2: Complete ALL forms in this Section

Every Year

Annual Patient Information Collection
Every year we have to update our records by law, so every year one needs to be completed. You will also be asked to upload a picture id.

HIPAA Policy
This is our HIPAA Compliance Policy that we are required to provide to all our patients. Signing it is optional, but we must provide it.

Payment for Visit
All payments must be received prior to clinician visit. Payment can be made using the above link or at Bohemian Alternative Health at The Grove (158 Bridgeport Ave, Milford CT 06460).

PTSD Only Forms, if Applicable

If you already have a PTSD diagnosis, use the “Upload” link provided below to upload the diagnosis from your doctor. Otherwise complete the LEC-5 and PCL-5 below.

Life Events Checklist (LEC-5) (PTSD only form, new certification)
This form along with the PCL-5 are the two main forms to help the clinician diagnose for PTSD. They help the clinician provide you with the best plan of care for your recovery.

PCL-5 (PTSD only form, new certification)
This form along with the Life Events Checklist (LEC-5) are the two main forms to help the clinician diagnose for PTSD. They help the clinician provide you with the best plan of care for your recovery.

Upload Proof of Diagnosis, if Applicable

Upload Files (Other than PTSD diagnosis)
Sometimes we need more information. This form enables the patient to upload addition documentation and clinical notes. If you are certifying for other than PTSD we will need a copy of your doctor’s notes supporting the diagnosis you are certifying for.

Step 3: The Visit

Waiting Room Check-in for Tele-Health
On the day of you appointment, click the link above 5 to 10 minutes prior to your scheduled appointment time to check-in to the waiting room.

For In-Person Visit we are located at:
156 Bridgeport Ave
Milford CT 06460

Call us at (203) 301-4006 with any questions.