SDBG New Patient Form

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

MonthDayYear
Date
Patient Name
Parent / Guardian Name if applicable.
Birth Sex
Gender Identity
Date of Birth

MonthDayYear
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)

Cancelof
Insurance Card (Back)

Cancelof
Subscriber's Name
Subscriber's Date of Birth

MonthDayYear
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!

Custody-Related Disclaimer
Please note that Southern Dutchess Behavioral Group does not provide evaluations, recommendations, or any opinions regarding custody-related matters. Our role is to support the mental health and well-being of our clients, and we do not participate in legal proceedings involving custody determinations.
Acknowledgment of Custody Disclaimer
Acknowledgment of Paperwork Requirements
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