SDBG New Patient Form

Please note that we are no longer accepting the following insurance plans:

NYSHIP (also referred to as Empire Plan, Carelon, or Beacon)
GHI
Emblem Health

Your policy may allow for out-of-network benefits. Please email us at Billing@sdutchessbg.com for more information.

⚠️ Important Notice
Clients will not be assigned to a clinician until all required portal paperwork is complete, including the Payment Authorization form, which requires a valid card on file.

Date

Patient Name

Parent / Guardian Name if applicable.

Birth Sex

Gender Identity

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile #

Format: (000) 000-0000.

Home or Other #

Email Address

example@example.com

Brief Description of the issues you're seeking help with.

Days and Times available.

In-person, telehealth, or either? ⚠️ Please Note: In-person appointments will take longer to schedule with a clinician compared to telehealth due to availability constraints. Please select your preferred option with that in mind.

Primary Insurance Provider (e.g., Aetna, MVP, etc.)

Insurance ID #

Insurance Card (Front)

Insurance Card (Back)

Subscriber's Name

Subscriber's Date of Birth

Date

Who referred you (how did you hear about us)?

Please describe any pending legal matters.

Anything you want us to know?

You will soon receive an invitation to our patient portal, TherapyNotes. Please note it will come from noreply@therapyportal.com.

To prevent automatic cancellation of your intake appointment, complete all required forms—including the Payment Authorization Form—in full at least three business days beforehand.

Once a therapist becomes available, we will reach out to you. While this process can take up to two weeks, we strive to contact you within one week.

We look forward to working with you!

Court and Custody-Related Matters Disclaimer

Please note that Southern Dutchess Behavioral Group does not provide custody evaluations, parenting evaluations, recommendations regarding custody or visitation arrangements, expert opinions, or forensic assessments. Our role is to provide mental health treatment and support the emotional well-being of our clients.

Additionally, our clinicians do not participate in court proceedings, provide testimony, write court-ordered recommendations, or render opinions regarding legal disputes between parties unless required by law or pursuant to a valid court order. Requests for custody evaluations, forensic services, or court-related recommendations should be directed to a qualified forensic mental health professional.

Acknowledgment of Court and Custody Disclaimer

Acknowledgment of Paperwork Requirements