Patient Forms

Below are most of the forms and links we use to help you get your medical marijuana card Connecticut.

Patient Forms:

Request an appointment
Here is where it all begins. Based on how you answer the questions on this form, links will be provided for additional forms that must be completed and additions information that is needed.

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.

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.

Medical Records Release Form
Use this form if you need to have your medical records sent to The Grove. You can complete the form online, print it, sign it and email it to your doctor’s office.

Life Events Checklist (LEC-5)
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
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 Files
Sometime we need more information. We always need some form of Proof of Identity. This form enables the patient to upload addition documentation, prescriptions and clinical notes.

Clinician Forms:

Medical Evaluation
After the patient meets with the clinician notes are necessary. This form is used by the clinician to record those notes.

PTSD Evaluation
This form is used by our clinician when evaluation a patient with PTSD.

Other Forms:

Change Dispensary Form
Please mail, e-mail or fax completed form to the Department of Consumer Protection, Attention Medical Marijuana Program:

Medical Marijuana Program
450 Columbus Boulevard
Suite 901 Hartford, CT 06103-1840

Fax: (860) 706-5361

E-mail: dcp.mmp@ct.gov