Intake Prescreen Form

Intake Prescreen Form

Initial Inquiry Form
Disclaimer
This form is for requesting outpatient therapy services and is not monitored 24/7. If you are experiencing a mental health emergency, are in crisis, or are having thoughts of harming yourself or others, do not wait for a response. Call 911, the crisis lifeline at 988, or go to the nearest emergency room.

If you need urgent care and are not comfortable being placed on a therapy waitlist, we strongly encourage you to seek immediate support through emergency services.

Please also note: This form is intended to be completed by prospective clients only. If you are a provider referring someone to Ackerman, please share this form directly with your client so we can assess their eligibility.

Si hablas español y prefieres completar este formulario en español, usa la opción de la bandera en la esquina superior para cambiar el idioma.

The Ackerman Approach to Therapy
The Ackerman Institute for the Family is an outpatient behavioral health provider licensed by the New York State Office of Mental Health as an Article 31 Clinic. Our clinic provides couples & family therapy, offering both in-person and virtual options.

Our nonprofit clinic provides world-class family therapy services to the public while training the next generation of family therapists.  We offer 3 distinct treatment tracks based on your needs. Each of our treatment tracks provide high quality mental health care.

Live Clinical Supervision Program

This live clinical program is a A 10-week course of therapy with a two-therapist team.

Therapists work in teams of 4–6 clinicians dedicated to your family’s treatment. All therapy is supervised by highly experienced, licensed professionals who observe and guide the clinical process. During your sessions, you may be observed by a supervision team that offers expert feedback to support your care.

Our clinic operates on an academic calendar, with new therapy cases typically beginning in September or October, and again in January or February. Sessions are held once per week.

Externship Program

At the Ackerman Clinic, our couples and family therapists-in-training work under the guidance of expert faculty instructors to provide you with high-quality mental health care.

For trainees, clinic experience is part of the required training and is completed under the supervision of licensed family therapists.

Clinic Therapist

Ackerman therapists are professionals from diverse cultural backgrounds and identities and provide care inclusive of race, gender, ethnicity, sexual orientation, country of origin, and ability.

Therapy at Ackerman is video recorded for training purposes. These recordings help our therapists provide the best possible care and are an important part of our internationally recognized training program. Videos are viewed only by therapy professionals and are permanently deleted at the end of treatment.

Placement is determined based on clinical and scheduling needs.

For more information and FAQ, please click here to be taken to our website.
Having read and understood the information provided, are you interested in pursing treatment at our clinic?*
Waitlist Information
Please note that due to high demand, our clinic often maintains a waitllist. After completing this pre-screening, undergoing insurance verification, agreeing to the cost of treatment, and completing your formal intake appointment, you may be placed on a waitlist while we work to match you with a therapist. Wait times vary depending on client volume and clinician availability, and unfortunately we are unable to provide a specific timeframe for the wait.
It may be a few weeks until we can match you with an appropriate Clinician once you complete the prescreening and intake processes. Are you comfortable with waiting?*

Introduction
The first step in the process is to complete an inquiry form, which helps us determine your eligibility for therapy at our clinic. Whether you're seeking couples or family therapy, we’ll just need one person’s information to get started.

The form takes approximately 30 minutes to complete. We'll ask for your insurance information (if applicable) to help verify coverage and review payment options. We’ll also collect some details about your therapy needs, who would be participating, and conduct a brief safety questionnaire to identify any potential risks that could affect treatment. Please note:
- All required fields must be completed. Missing or incomplete information may result in delays in processing of your registration.
- Your responses are submitted through a HIPAA-compliant, encrypted platform, ensuring your data remains private and secure. Only authorized Ackerman staff will have access to this information, which will be used solely to assess eligibility for therapy services at our clinic.
Once you complete our pre-screening form, our team will review your information to ensure you meet eligability for our program. One of our team members will then reach out to you to continue to gather additional details, secure needed consents and other required paperwork, verify any insurance benefits, and set up a intake appointment.
Do we have your permission to proceed with prescreen?*

Pre-screen

Background Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
By providing your email, you consent to receive communications from our Intake Team about your eligibility status and next steps.
What is your date of birth?*

MonthDayYear
Date
Have you ever been a client at the Ackerman Institute before?
If "Yes", please specify when you received services and what type of services they were.
How did you hear about Ackerman's clinical services?
If you selected "Referral from an agency or provider," please list the name of the agency or provider below.
If you selected "Other," please describe below.
In what language do you prefer to receive treatment?*
If you selected "Other," please describe below.
Please note that services are currently available only in English and Spanish.
Do you have any accessibility needs or require any accommodations to participate in services (e.g., ASL interpretation, mobility assistance, or other support)?
If "Yes," please specify.

Therapy Logistics
What brings you to therapy?

The following questions are intended to help our Intake Team better understand your reasons for seeking treatment at this time. While detailed responses are appreciated, we encourage you to keep your answers brief. Please note that you will have a formal intake appointment during which we will ask similar questions and give you the opportunity to provide more in-depth responses.
What has led you to seek therapy at this time? Feel free to include any specific events, concerns, or patterns you've noticed. The more you share, the better we can understand your goals and needs.*
Are you looking for in-person or virtual therapy sessions?*

In PersonVirtual
If you start with one format (in person) and want to switch to a different format (virtual) or vice versa, you can do so. Keep in mind this may require you to return to the waitlist if your therapist does not have any openings in the other format. Do you understand that you can request to change how your therapy is delivered (e.g., telehealth or in-person) at any time?*
Are you looking for couples or family therapy at this time?
Have you discussed therapy with your partner or family members, and are they willing to attend?*
Please indicate how many people (including yourself) will be participating in therapy.*
Please provide the first name, last name, relationship to you, and age of anyone (other than yourself) who will be attending therapy.*
Which state is the identified patient a resident of?*
Will any participating family members or partners be located outside of New York during telehealth sessions?*
If "Yes," please list the state(s) where they will be located during sessions:
Are there any custody arrangements, court orders, or legal agreements we should be aware of regarding any children who may be attending therapy?*
If yes, please provide a brief explanation below. Our Intake team will follow up if any additional documentation is needed, based on the notice below.
Important Note:

If your child is under the age of 18 and you are separated or divorced, our Intake team will request documentation of your current custody arrangement.
- If one parent has sole legal custody, we will need documentation confirming this before services begin.
- If parents share joint legal custody, we require written consent from both parents before initiating therapy, regardless of who will be attending the sessions.
- If appropriate consent cannot be obtained, we may not be able to proceed with treatment.
This process ensures we remain compliant with New York State laws and helps protect the therapeutic relationship by establishing clear expectations from the start. Thank you for your understanding and cooperation!
To help us match you with a therapist, please provide the days and times you will be available for therapy sessions. The more flexible your availability, the better we can accommodate your schedule and connect you with a therapist.*
After we gather all the background information, you may be placed into either a short-term, 10-week treatment with two therapists or in ongoing, open-ended treatment with one therapist, based on your needs and our clinical recommendation. Do you understand this? *
As a reminder, therapy at Ackerman is video recorded to support the training and development of our clinicians. We appreciate your role in helping us train the next generation of family therapists. While you may opt out of recording, please note that doing so may extend your wait time, as most cases are seen within our training program.
Do you consent to video recording and live observation of your sessions?*
Telehealth (Virtual) Therapy Services
For telehealth sessions, do you have access to a secure and private space for therapy?*
To help ensure good video and sound during your telehealth sessions, we recommend using a laptop or desktop if possible. Do you have access to a device—such as a laptop, desktop, tablet, or smartphone—that you can use for telehealth sessions?*
Do you have a stable internet connection that supports video calls? *

Thank You for Your Interest

We acknowledge your decision not to proceed with the registration process at this time. We appreciate your interest in couples or family therapy and your consideration of our services.

Should your needs or circumstances change, we welcome you to reach out in the future. Our team remains available to support you when you're ready.

— The Ackerman Institute Intake Team

Safety Questionnaire

To help us ensure a safe and supportive therapeutic environment, please take a moment to complete the following safety screening questions. Your responses are confidential and will help us determine the most appropriate next steps for your care. Thank you for your cooperation.
Have there ever been any incidents of physical violence among people interested in attending therapy?*
If yes, can you share when the most recent incident took place and who was involved?
Were the police or medical professionals involved?
If yes, what was the outcome of their involvement?
How did this experience affect your relationship with the other person/people involved?
How often has physical violence occurred between partners, family members, or others you live with or interact with regularly?

Safety Questionnaire
For anyone attending therapy, are there any current or past substance or alcohol use concerns?*
If yes, how frequently is substance or alcohol use occurring?
How is their substance or alcohol use affecting their life? Does this person believe it is affecting their life?
Are they currently receiving support or treatment for substance or alcohol use? What does their support system look like?

Safety Questionnaire
Is anyone who will be participating in therapy currently experiencing suicidal ideation (e.g., thoughts of wanting to die or ending their life), engaging in self-harm behaviors, or having homicidal thoughts (e.g., thoughts of seriously harming another person)? *
If yes, when was the most recent episode or incident?
To your knowledge, did this person have a clear plan to harm themselves, end their life, or hurt someone else, or did they take any steps toward acting on those thoughts?
What was the outcome? Was there any hospitalization, emergency intervention, or involvement with a safety or legal system (e.g., police, child protective services, or other agencies)?
Is this individual currently engaged in any treatment or receiving support related to these thoughts or behaviors?

Safety Questionnaire
Have there been any psychiatric hospitalizations, either recently or in the past?*
When did the most recent hospitalization occur, and what were the circumstances surrounding it? If there is a history of previous hospitalizations, please include the dates and a brief description of what led to those as well.
Has the individual been engaged in any treatment or support services since their most recent hospitalization?

Safety Questionnaire
Has there been any involvement with legal or safety services, such as child protective services(CPS), adult protective services (APS), orders of protection, or court cases related to criminal, family, divorce, or custody matters? *
Is the involvement ongoing?
What are the circumstances surrounding the open case?
Are you currently seeking treatment as a result of legal or safety-related mandates connected to this case?
If yes: Please be advised that our Intake team may request documentation related to this matter to help us determine whether our clinic is the right fit for your therapeutic needs. If necessary, we may also ask you to sign a release form granting us permission to communicate with the relevant legal or protective services for additional information and clarification.Please note that our clinic does not provide testimony or treatment updates for any legal proceedings, including criminal, family, divorce, or custody matters.
If the case was closed, what was the outcome?

Insurance Eligibility and Verification

If you plan to use insurance, please have your information ready and complete all fields below. Incomplete information may delay or prevent our Intake Team from processing your request for services.
Please note: For billing purposes, the person in the couple or family whose insurance will be used (i.e., the “identified patient”) must be a resident of New York.
We are in-network with the following insurance:
- Beacon Health
- BCBS (except plans whose member ID’s start with JLJ, JLH or BCBS Medicaid)
- Emblem Health
- GHI
- Healthfirst
- MetroPlus
- MHAP
- NY State Health Insurance Plan (NYSHIP)
- Optum
- Oxford
- United Behavioral Health
- United Behavioral Health Community Plan
- UMR
- United Healthcare
- Value Options
We accept straight Medicaid and Medicaid plans attached to a plan we are in network with (aside from BCBS as indicated above).

We are not in-network with Medicare and are unable to accept a secondary plan if your primary plan is Medicare.

Out-of-pocket payments are accepted for out-of-network or uninsured families. We do offer a sliding scale fee based on income. Our full fee is $300 per therapy session. We accept American Express, Visa, and MasterCard.
How do you intend to pay for treatment? *
What is the name of your insurance company?*
Please provide clear photos of both the front and back of your insurance card. You may either upload existing images from your device or, if you're using a mobile device, use the 'Take Photo' option to capture and upload photos with your camera.

Cancelof
Take a clear photo of the front of your insurance card (if you are not uploading an existing image).
Take a clear photo of the back of your insurance card (if you are not uploading an existing image).
In the space below, please enter the full name, date of birth, and billing address on file with the insurance company.
If your insurance provider isn’t listed among those we accept, do you happen to know if you have out-of-network benefits?
If so, please follow the guidelines above to submit a copy of the front and back of your insurance card, along with the requested information (e.g., your name, date of birth, and the billing address on file with your insurance provider). We will still verify your insurance to determine how your plan may apply to services at Ackerman.
Do you have a secondary insurance policy (e.g., additional coverage that activates after your primary insurance has paid its share)?
Please provide clear photos of both the front and back of your insurance card. You may either upload existing images from your device or, if you're using a mobile device, use the 'Take Photo' option to capture and upload photos with your camera.

Cancelof
Take a clear photo of the front of your secondary insurance card (if you are not uploading an existing image).
Take a clear photo of the back of your secondary insurance card (if you are not uploading an existing image).
In the space below, please enter the full name, date of birth, and billing address on file with the secondary insurance company.
If the insurance of the person completing this form is not listed among our accepted plans, does anyone else who would be attending therapy with you have an insurance plan we accept?
Please provide clear photos of both the front and back of your insurance card. You may either upload existing images from your device or, if you're using a mobile device, use the 'Take Photo' option to capture and upload photos with your camera.

Cancelof
Take a clear photo of the front of that insurance card (if you are not uploading an existing image).
Take a clear photo of the back of that insurance card (if you are not uploading an existing image).
In the space below, please enter the full name, date of birth, and billing address on file with this insurance company.
Please note: It’s important that everyone participating in therapy is aware of the commitment involved and willing to attend. The formal intake appointment—your first billed session—will include all individuals involved in the therapy process.

We recommend reviewing the Start Here page on our website with everyone you expect to participate, to ensure they understand and agree with the Ackerman approach to therapy.

Thank you for completing our prescreen form. We look forward to the opportunity to serve you in the near future.
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Intake Prescreen Form

Disclaimer

The Ackerman Approach to Therapy

Waitlist Information

Introduction

Pre-screen

Therapy Logistics

What brings you to therapy?

Telehealth (Virtual) Therapy Services

Safety Questionnaire

Safety Questionnaire

Safety Questionnaire

Safety Questionnaire

Safety Questionnaire

Insurance Eligibility and Verification

We are in-network with the following insurance: