ECMC Client Appointment Request Form

ECMC Appointment Request Form
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
NoYes
Name of parent or guardian

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Insurance Provider*
Insurance ID Number
YesNoNot Sure
Co-pay amount
Insurance Card (Optional)

Cancelof
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AnxietyAddiction/Substance AbuseAnger ManagementChild and Adolescent CounselingDepressionEducational CounselingMarriage CounselingMood DisorderStress ManagementPersonality DisorderRecent loss/ BereavementRelationship IssuesTraumaEating DisorderPost Traumatic StressEMDRFamily CounselingPrescription ServicesPsychiatric CareVeteran ServicesOther/ additional backgroundParole ProgramGroup CounselingNYLEAP
Group Counseling Topic
Parole Officer Name
Parole Officer Email
example@example.com
Parole Officer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parolee Release of Information

Cancelof
Other/ additional background:
Prescription Services/ Psychiatric Care are provided through our virtual partner agencies. To request or schedule an appointment, please complete the forms through their portals as well.

For Fulton Family Psychiatry:

https://www.fultonfamilypsychiatry.org/appointments

For Green Wellness

https://form.jotform.com/Green_Wellness/med-management-intake

For Timothy Greco, NP (Commercial plans only)

https://www.timgreconp.com
AnytimeMorningAfternoonEveningWeekend
Provider Preference*
Provider Gender Preference*
Preferred Counseling Method*
How did you hear about us?*
Upload any pertinent documents that you would like your provider to review.

Cancelof
MyselfParent/GuardianCare CoordinatorSchool CounselorHospital Discharge PlannerOther
Discharge Planner Email
example@example.com
NoYes
Appointment Preference (Appointments must be made within 7 days of discharge)

MonthDayYear
Date
Hour MinutesAM/PM Option
YesNo
Peer Name
Peer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

ECMC Appointment Request Form