New Client Registration Form (Adults)

New Client Registration

CLIENT DEMOGRAPHICS
Today's Date*

MonthDayYear
Client Legal Name*

First NameLast Name
Preferred Name (if different from above)
Client Date Of Birth*

MonthDayYear
Client's Current Age*
Race/Ethnicity*
Gender Identity*
Sexual Identity*
Marital Status*
Please Select
Are you currently sexually active?*
Partner's Name*

First NameLast Name
Partner's Date Of Birth*

MonthDayYear
Partner's Age*
Employment Status*
Profession/Occupation*
Employer*
School*
Area of Study*
Expected Graduation Date*

MonthDayYear
Have you served in the military?*

YesNo
Client Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Client Email*
example@example.com
Client Mobile Number *
Please enter a valid phone number.
Please select ALL that apply:*

I consent to receiving text messagesI DO NOT consent to receiving text messagesI consent to receiving phone calls/voice messagesI DO NOT consent to receive phone calls/voice messagesI consent to receiving emailsI DO NOT consent to receiving emails
Whom May We Thank for Referring You?

New Client Registration

CLIENT ID & INSURANCE VERIFICATION
Please upload both FRONT and BACK of a Government-Issued Photo ID
ID (Front)*
ID (Back)*
INSURANCE
Will you require proof of payment (Superbills) for Out-Of-Network Insurance Reimbursement?*

YesNoUndecided
Insurance Card (Front)*
Insurance Card (Back)*
Subscriber Name*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Subscriber Relation to Client*
Primary Insurance Provider*
Policy ID Number*
Group Number*
Insurance Phone
Please enter a valid phone number.
Insurance Address (if known)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

New Client Registration

EMERGENCY INFORMATION
Emergency Procedures Specific to Telehealth Services
It is important to understand that there are additional procedures that are necessary to have in place specific to Telehealth. These are for your safety in the case of an emergency and are as follows:
1. You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or are in a crisis that we cannot resolve remotely, I may determine that a higher level of care is necessary and that Telehealth Services are not appropriate.
2. You understand that you are required to identify and provide information for at least one Emergency Contact Person who may be contacted on your behalf in the event of a life-threatening emergency.
It will be required that either you or I verify that your Emergency Contact Person is willing and able to go to your location should an emergency situation ever arise. Additionally, if at any time, either you or I determine that it is necessary, the identified individual should be willing and able to take you to the hospital.

New York State Law requires that you be in the State of New York at the time of service. As such, it is imperitive that you notify me should you ever decide to conduct sessions in a location other than originally indicated.
Location of Services
Your safety and our work together are of the utmost importance. Please indicate where you regularly intend to hold your sessions.
Please check the following to ensure that has been selected can provide the following:*

Private EnvironmentConfidential LocationComfort SpaceStable InternetQuiet, Limited Background NoiseAdequate Lighting (if applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #1
Contact Name (Must be local)*

First NameLast Name
Relationship to Client*
Mobile Phone*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #2
Contact Name*

First NameLast Name
Relationship to Client*
Mobile Phone*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client Intake Form

MEDICAL HISTORY
Do you have a Primary Care Provider (PCP)?*

YesNoDecline Answer
Provider Full Name*
Provider Phone*

Area CodePhone Number
Provider Email
Do you give consent for your Provider to be contacted?*

YesNo
Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client Intake Form

ADHD SELF-REPORT SCALE (ASRS V1.1) SYMPTOM CHECKLIST
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?*
How often do you have difficulty getting things in order when you have to do a task that requires organization?*
How often do you have problems remembering appointments or obligations?*
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?*
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?*
How often do you feel overly active and compelled to do things, like you were driven by a motor?*
How often do you make careless mistakes when you have to work on a boring or difficult project?*
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?*
How often do you have difficulty concentrating on what people say to you, even when they are speking to you directly?*
How often do you misplace or have difficulty finding things at home or at work?*
How often are you distracted by activity or noise around you?*
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?*
How often do you feel restless or fidgety?*
How often do you have difficulty unwinding and relaxing when you have time to yourself?*
How often do you find yourself talking too much when you are in social situations?*
When you are in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish themselves?*
How often do you have difficulty waiting your turn in situations when turn-taking is required?*
How often do you interrupt others when they are busy?*

Client Intake Form

OBSESSIVE COMPULSIVE TEST
*OBESSIONS ARE FREQUENT, UNWELCOME, AND INTRUSIVE THOUGHTS.
How much time do you spend on obsessive thoughts?*
How much do your obsessive thoughts interfere with your personal, social, or work life?*
How much do your obsessive thoughts distress you?*
How hard do you try to resist your obsessions?*
How much control do you have over your obsessive thoughts?*
*COMPULSIONS ARE REPETITIVE BEHAVIORS OR MENTAL ACTS THAT YOU HAVE A STRONG URGE TO REPEAT THAT ARE AIMED AT REDUCING YOUR ANXIETY OR PREVENTING SOME DREADED EVENT.
How much time do you spend performing compulsive behaviors?*
How much do your compulsive behaviors interfere with your personal, social, or work life?*
How anxious would you feel if you were prevented from performing your compulsive behaviors?*
How hard do you try to resist your compulsive behaviors?*
How much control do you have over your compulsive behaviors?*

Client Intake Form

CAGE - AID
WHEN THINKING ABOUT DRUG USE, INCLUDE ILLEGAL DRUG USE AND THE USE OF PRESCRIPTION DRUGS NOT USED AS PRESCRIBED.
Have you ever felt that you ought to cut down on your drinking or drug use?*

YesNo
Have people annoyed you by criticizing your drinking or drug use?

YesNo
Have you ever felt bad or guilty about your drinking or drug use?*

YesNo
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?*

YesNo

	DATES	DURATION OF STAY	HOSPITAL	REASON FOR ADMISSION	VOLUNTARY?
#1
#2
#3
#4
#5
#6

	DATES	DURATION	REASON	NAME	LICENSURE	DEGREE OF SATISFACTION
#1
#2
#3
#4
#5
#6

	MEDICATION NAME	PURPOSE	DOSAGE	DURATION ON MED	PRESCRIBING MD	EFFECTIVENESS	SIDE EFFECTS
#1
#2
#3
#4
#5
#6

	Not at All	Several Days	More than Half the Days	Nearly Every Day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying alseep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

	Not at All (0)	Several Days (+1)	More than Half the Days (+2)	Nearly Every Day (+3)
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid, as if something awful might happen

New Client Registration

New Client Registration

INSURANCE

New Client Registration

Emergency Procedures Specific to Telehealth Services

Location of Services

Your safety and our work together are of the utmost importance. Please indicate where you regularly intend to hold your sessions.

Emergency Contact #1

Emergency Contact #2

Client Intake Form

Presenting Problem

Client Intake Form

Smoking Status

Client Intake Form

Client Intake Form

Client Intake Form

If you currently see a mental health provider, please complete the section below.

New Client Registration

Client Intake Form

New Client Registration

Client Intake Form

Client Intake Form

Client Intake Form

Client Intake Form

Client Intake Form