If you are a new patient, interested in scheduling your first appointment, please complete the following NEW PATIENT SUBMISSION FORM which includes your insurance information.
For expediency in getting scheduled with a medication provider, please have your current therapist complete this form to supply information about your current care. This will help us to identify a provider who might match well with your clinical needs. Therapists can provide their information in the box labeled “what are you looking for help with”.
Fill out online as directed
Do not fill these out until after you have an appointment scheduled.
- New Patient History
- Patient Health Questionnaire
- Generalized Anxiety Disorder
- Mood Disorder Questionnaire
- Medication & Controlled Substance Agreement
- Authorization for release of health information pursuant to HIPAA
- Rochester RHIO Authorization for Access to Patient Information
- New Patient Information & Office Policies
- Notice of Privacy Practices Receipt & Acknowledgement of Notices
- Telehealth Consent
- COVID-19 Liability Release
For Children and Adolescents – Fill out as directed
Do not fill these out until after you have an appointment scheduled.
- Child / Adolescent New Patient History
- Adolescent PHQ-9 Form
- Adolescent Generalized Anxiety Disorder Measure
- Medication & Controlled Substance Agreement
- Authorization for release of health information pursuant to HIPAA
- New Patient Information & Office Policies
- Notice of Privacy Practices Receipt & Acknowledgement of Notices
- Telehealth Consent
- COVID-19 Liability Release
Forms for Psychological Testing – Fill out online as directed
Do not fill these out until after you have an appointment scheduled.
- Psychological Testing History – Adult
- Psychological Testing History -; Child / Adolescent
- Authorization for release of health information pursuant to HIPAA
- New Patient Information & Office Policies
- Notice of Privacy Practices Receipt & Acknowledgement of Notices
- Telehealth Consent
- COVID-19 Liability Release