New Client Registration (Adult, Individual)

New Client Registration

CLIENT ID & INSURANCE VERIFICATION
Please complete the following
- Please upload both FRONT and BACK of a Government-Issued Photo ID
- ID (Front)*
- ID (Back)*
- YesNoUndecided
- Insurance Card (Front)*
- Insurance Card (Back)*
- Subscriber Name*
  
  First NameLast Name
- Subscriber Date of Birth*
  
  MonthDayYear
- Subscriber Employer*
- Relationship to Client*
- Policy ID Number*
- Group Number*
- Insurance Phone*
  Please enter a valid phone number.Format: (000) 000-0000.
- Insurance Address (if known)*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code

New Client Registration

EMERGENCY CONTACT 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.
Pertaining to Location of Services
Your safety during our time together is of the utmost importance.
For this reason, in the event of emergency it is important for me to know where you regularly intend to hold your sessions.
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 Information
Please complete the following
- Full Name *
  
  First NameLast Name
- Relationship to Client*
- Mobile Phone*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email*
  example@example.com
- Emergency Contact Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Full Name*
  
  First NameLast Name
- Relationship to Client*
- Mobile Phone*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email*
  example@example.com
- Emergency Contact Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code

Client Intake Form

COORDINATION OF CARE
YesNoDecline Answer
Provider Name*

First NameLast Name
Provider Phone*

Area CodePhone Number
Provider Email*
YesNo
Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

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

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

Rows	Yes	No	Age at First Use	Date of Last Use	Qty Used in the Last 30 days
Marijuana
Cocaine
Amphetamines
Heroin, Morphine, Codeine
Methamphetamine
Ecstasy
Stimulants
PCP
Benzodiazepines
Barbiturates
Methaqualone
MDMA
Oxycodone, Hydrocodone
Buprenorphine
Fentanyl
Ketamine
Mushrooms, Psychedelics, LSD
Prescription RX Abuse/Misuse
Alcohol/Drug Overdose
Alcohol/Drug Blackout
Alcohol/Drug Withdrawal
Non-Rx/ Over-the-Counter Drug Misuse/Abuse
Trouble Stopping any Substance
Inhalants
Other

New Client Registration

New Client Registration

New Client Registration

Emergency Procedures Specific to Telehealth Services

Pertaining to Location of Services

Your safety during our time together is of the utmost importance. For this reason, in the event of emergency it is important for me to know where you regularly intend to hold your sessions.

Emergency Contact Information

Client Intake Form

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

Client Intake Form

Client Intake Form

Client Intake Form

Your safety during our time together is of the utmost importance.
For this reason, in the event of emergency it is important for me to know where you regularly intend to hold your sessions.