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New Patient Form
Home
Children & Adolescents
Adults
Education
ABA
New Patient Form
Intake Form
Intake
Patient Information
Form Status [hidden]
📬 New
Patient's First Name
Patient's Last Name
Date of Birth
Assigned Sex at Birth
- Select -
Male
Female
Current Gender Identity
- Select -
Male
Female
Gender Diverse
Further Details
Patient is:
Child (Under 18)
Adult (18 and over)
Patient's Street Address
Patient's City
Patient's State
Patient's Zip Code
County
- Select -
Oneida
Herkimer
Madison
Onondaga
Lewis
Other
What County?
Preferred Office Location
Utica
Syracuse
Rochester
Responsible Party Information
Required
Is the patient the responsible party?
No
Yes
Relationship to the patient
- Select -
Biological Mother
Biological Father
Adoptive Mother
Adoptive Father
Step Mother
Step Father
Grandmother
Grandfather
Aunt
Uncle
Husband
Wife
Spouse
Legal Guardian
Self
Other
First Name
Last Name
Email Address
Phone 1
Type
- Select -
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Phone 2
Type
- Select -
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Phone 3
Type
- Select -
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Second responsible party
Optional
Relationship to the patient
- Select -
Biological Mother
Biological Father
Adoptive Mother
Adoptive Father
Step Mother
Step Father
Grandmother
Grandfather
Aunt
Uncle
Husband
Wife
Spouse
Legal Guardian
Self
Other
First Name
Last Name
Email
Phone 1
Type
- Select -
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Phone 2
Type
- Select -
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Phone 3
Type
- Select -
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Referral Information
Please Choose One
Self-referred
Referred by Provider
Other
Provider's Name
How were you referred?
Concerns and Goals
What are your concerns with your child's behavior?
What are your concerns/reasons for coming here?
What is your goal for completing an evaluation with us (check all that apply)?
Engage in treatment for my child
Apply for other programs
Obtain school services
Obtain a medication recommendation
Obtain a referral for another treatment provider
Other
Explain 'Other' Goals
If you are interested in treatment appointments, please list your available days and times.
If there are not currently times that match your availability, would you be interested in being placed on a wait list?
Yes
No
Are you seeking a custody evaluation?
Yes
No
Was this evaluation court ordered?
Yes
No
Patient History
CHILD ⬇️
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Has your child ever been diagnosed with any mental health, behavioral or emotional disorders?
Yes
No
Please list all diagnoses.
Is your child currently seeing a mental health provider?
Yes
No
Please enter the current mental health provider.
Has your child ever received mental health treatment with someone other than the provider listed above?
Yes
No
Please enter your child's past mental health provider and when received.
Is your child currently taking any stimulant medications?
Yes
No
Please enter your child's stimulant medications.
Is your child currently taking any other medications for mental health, behavioral health, or emotional problems?
Yes
No
Please enter your child's medications.
Does your child or has your child ever seen a psychiatrist?
Yes
No
Please list name(s) and when last seen.
Does your child currently see, or has your child ever seen a neurologist?
Yes
No
Please list name(s) and when last seen.
Do you suspect that your child has any of the following?
Autism
ADHD
Dyslexia
Depression
Anxiety
Intellectual Disability
Has your child had any of the following?
Head injury/concussion
Loss of consciousness
Seizure (not due to fever)
Lead poisoning
Brain infection
Significant premature birth
Very low birth weight
Exposure to cigarettes, drugs, alcohol, or prescription medication during pregnancy
Loss of oxygen (during birth or otherwise)
ADULT ⬇️
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Have you ever been diagnosed with any mental health, behavioral or emotional disorders?
Yes
No
Please list all diagnoses.
Are you currently seeing a mental health provider?
Yes
No
Please enter the current mental health provider.
Have you ever received mental health treatment with someone other than the provider listed above?
Yes
No
Please enter your past mental health provider and when received.
Are you currently taking any stimulant medications?
Yes
No
Please enter your stimulant medications.
Are you currently taking any other medications for mental health, behavioral health, or emotional problems?
Yes
No
Please enter your medications.
Do you or have you ever seen a psychiatrist?
Yes
No
Please list name(s) and when last seen.
Do you or have you ever seen a psychiatrist?
Yes
No
Please list name(s) and when last seen.
Do you suspect that you have any of the following?
Autism
ADHD
Dyslexia
Dementia
Depression
Anxiety
Intellectual Disability
Have you ever had any of the following?
Head injury/concussion
Loss of consciousness
Seizure (not due to fever)
Lead poisoning
Brain infection
Significant premature birth
Very low birth weight
Exposure to cigarettes, drugs, alcohol, or prescription medication during pregnancy
Loss of oxygen (during birth or otherwise)
Insurance Information
Are you Self-Pay?
No
Yes
Insurance Company
Phone Number
ID Number
Policy/Group/Seq Number
Is the patient the insured?
No
Yes
Insured's First Name
Insured's Last Name
Insured's Birthday
Insured's relationship to patient
- Select -
Biological Mother
Biological Father
Adoptive Mother
Adoptive Father
Step Mother
Step Father
Grandmother
Grandfather
Aunt
Uncle
Husband
Wife
Spouse
Legal Guardian
Self
Other
Is the patient currently receiving Social Security Disability benefits?
No
Yes
Are you in the process of applying for Social Security Disabilities benefits?
No
Yes
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