2025 New Patient Forms

New Patient Registration
Today's Date

MonthDayYear
Date
Age
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Your Name

First NameLast Name
Sex/Gender*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Is there Court Ordered Custody?

YesNo
If there is Court Ordered Custody, we require a copy of the order to review. This can be provided to us by email, fax, or by mail

Email: admin@newdaycps.com

Fax: 724-434-7889

1301 E Washington St.

New Castle, PA 16101
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Communication Permissions: Please check all that apply*

Okay to Leave VoicemailOkay to EmailOkay to Send MailSMS (text message) Appointment RemindersEmail Appointment Reminders
Emergency Contact*

First NameLast Name
Emergency Contact Phone:*
Please enter a valid phone number.
Employment Status
Marital Status
Patient Identifies As:
Hold Ctrl+click to select/unselect options
Patient Identifies Race/Ethnicity/Culture as:
Patient Identifies Religion/Spirituality as:
How were you referred to our practice?

Psychology TodayGoogle Search/WebsiteFriend/FamilyProfessional ReferralOther
Professional Referral Source:
Please describe your reasons for seeking help: *
Please list all health care practitioners, including your Primary Care Physician, Psychiatrist, etc. *
Please list all prior experiences with mental health and/or substance abuse treatment providers or hospitalizations including dates of treatment:*
Please list all medication and/or nutritional supplements that you're taking:
Tobacco Use
When did you quit?
Insurance Information
Primary Insurance:*
Subscriber ID: *
Group Number: *
Policy Holder:*

SelfSpouseParentOther
Policy Holder Name:

First NameLast Name
Policy Holder DOB:

MonthDayYear
Date
Policy Holder Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do You Have Secondary Insurance?*

YesNo
Secondary Insurance:
Secondary Insurance ID:
Secondary Group Number:
Release and Assignment:

I authorize the release of any information necessary to process my insurance claims and assign and request payment directly to the above provider. I am aware that an agent of my insurance company or other third-party payer may be given information about the type, cost, date, and provider of any services or treatment I, or my dependent receives. I understand that if payment for the services I receive is not made by the insurance company, I am responsible for full payment. If payment is not made in a reasonable amount of time the above provider may stop my treatment
Date

MonthDayYear
Date
Signature*

Clear
Signer Relationship to Patient*

SelfSpouseParentOther
Name of Person Signing: *

First NameLast Name

Agreement for Services

Thank you for choosing this practice. This form outlines important information regarding the services offered. Please review this form carefully, then initial and sign where indicated.

Fees and payments

Current Fees:

Initial Evaluation	$250.00
Individual Psychotherapy	$190.00
Family/Couples Therapy	$250.00
Group Therapy	$80.00

If you are using third-party benefits (such as health insurance) to pay for services, our office will verify your benefits and submit claims directly to your benefits carrier.

Please be aware that patients maintain ultimate responsibility for knowing the coverage provided by a third-party benefits carrier. Payment for services is due at each session. Please be prepared to provide payment for any amount of each session fee that is your responsibility including coinsurance and copayments. We accept cash, checks, and credit cards. A $25 charge will be assessed for checks returned by a financial institution due to insufficient funds.

Any account with an outstanding balance more than 90 days past due, without a payment arrangement approved by this office, will be sent to a collection agency. Patients are responsible for both their account balance and a 40% (of the account balance) collections fee in these situations.

Appointments

Length of sessions:

Initial Evaluation	60 Minutes
Individual Psychotherapy	60, 45, or 30 Minutes
Family/ Couples Therapy	45 Minutes
Group Therapy	90 Minutes

Please arrive on time for your appointments as appointments generally cannot be extended due to late arrivals. Cancellations made with less than 24 hours notice and missed appointments may be assessed a full session rate fee. These charges cannot be submitted to a third-party benefits carrier and are fully the responsibility of the patient.

Emergencies

Please attempt to contact your clinician at the office telephone number if you are having a mental health emergency. The voicemail message will provide an alternative telephone number for emergencies that occur outside of regular office hours if you are unable to reach your clinician.

Confidentiality

The patient-clinician relationship is confidential. No information about you or your treatment here will be shared with any third party unless permission is given. Your clinician will ask you to sign a consent to release and/or obtain information regarding your treatment if at any time communication with a third party is required. According to legal and ethical guidelines, confidentiality will only be broken if you make your clinician aware that you intend to harm yourself or another person. Your clinician is also a mandated reporter for child abuse; your clinician must report any child abuse brought to their attention.

Patient Bill of Rights

You have the right to be treated with dignity and respect, including respect for cultural diversity, in an environment free from physical, emotional, and sexual abuse.

You have the right to inquire about your clinician’s qualifications including education, professional experience, licensure, and professional membership.

You have the Right to Privacy and Confidentiality as defined in this Agreement for Services and the Notice of Privacy Practices.

You have a right to be actively involved in your treatment planning and process and to request information from your clinician needed to make informed treatment decisions.

You have the right to ask your clinician how your health care benefits work and will apply to the treatment process.

You have a right to voice any concerns about the treatment process to your clinician and you have the right to all remedies for grievances explained in the Notice of Privacy Practices.

You have the right to terminate treatment and request a referral to an alternate treatment provider.

I acknowledge that I have received and read this Agreement for Services in its entirety and that I will abide by the contents of this agreement*
I also acknowledge I have been offered a copy of the Notice of Privacy Practices and am aware I can obtain copies at my request*
New Day Counseling & Psychiatric Services, LLC reserves the right to make changes to this Agreement for Services at any time.
Signature of Patient (or Parent/Guardian)*

Clear
Date

MonthDayYear
Date

Consent for Psychological Services

INITIAL ALL THAT APPLY. Your consent is required for a clinician to provide treatment; therefore it is necessary to initial the first 2 items, Clinical Interview and Psychotherapy if you wish to receive services.
I consent for the following psychological services for myself or my dependents:
Clinical Interview*
Counseling/Psychotherapy: Individual, Family, Marital, or Group Therapy*
Share appointment information with:
Person to Share Information With:

First NameLast Name
(this is to designate another person who is allowed to schedule, cancel, and
confirm appointments on your behalf – this does not permit this person to obtain
any other information about your treatment; you may decline to initial)
Consultation with Physician:
(please provide physician name & address – this allows us to exchange information with your Primary Care Physician; you may decline to initial)
I understand and agree to above identified services and clinical interviews for the sole purpose of my treatment. I am aware that I may revoke this consent at any given time in treatment in compliance with state and federal regulation regarding confidentiality. I am aware of the responsibilities of my treating clinician in situations of “Duty to warn”.
Signature of Patient (or Parent/Guardian)*

Clear
Date

MonthDayYear
Date
Patient Name*

First NameLast Name

Consent for Telehealth Services
I consent to receive treatment in the form of telehealth services. I understand that when using telehealth services I am virtually visiting my provider’s office in Pennsylvania, where my provider is licensed.

Except in cases where other laws or regulations stipulate otherwise, all services will be rendered under the laws and regulations of Pennsylvania and within my provider’s legal scope of practice within Pennsylvania. I understand that my provider is using a secure teleconference connection, which uses live two way audio and video, in order to comply with thelaw and protect my privacy.

I understand that all provisions of the Agreement for Services and Consent for Services apply to this like all other services rendered
Date

MonthDayYear
Date
Patient Name

First NameLast Name
Signature of Patient (or Parent/Guardian)

Clear

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New Patient Registration

Insurance Information

Release and Assignment:

Agreement for Services

Consent for Psychological Services

I consent for the following psychological services for myself or my dependents:

Consent for Telehealth Services

Scheduling