• Nike Carli, LCSW-R

    Nike Carli, LCSW-R

    5500 Main Street, Suite 259, Williamsville, New York 14221 Phone: 716-633-6900

  • New Patient Office Visit Forms

  • Please provide the following as best you can. I appreciate your willingness to cooperate in helping me obtain your history and information.

    • Patient Information 
    • Date*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Gender*
    •  -
    • Insurance Information: Please List All Insurances 
    • Will you be utilizing insurance as a form of payment*
    • Is pre-authorization required?
    • Effective Date
       - -
      2 digit month, 2 digit day, 4 digit year
    • Have you used your benefits this year with any other counseling service?
    • Is pre-authorization required?
    • Effective Date
       - -
      2 digit month, 2 digit day, 4 digit year
    • Have you used your benefits this year with any other counseling service?

    • I authorize the release of any medical or other information necessary to process any insurance claim(s). I also authorize payment of medical benefits for services described on above mentioned claim(s). I understand that I am ultimately responsible for payment of all services rendered and that I will be charged for appointments if canceled with less than 24 hours notice. In order to utilize insurance, I understand that all copays must be paid at time of service.

    • Signature
    • Patient History 

    • Prior Mental Health History

    • Have you ever seen a psychiatrist, therapist, or counselor?*
    • Have you been or are you on medication? (tranquilizers, antidepressants, others)*

    • Family History

    • Do any members of your family (grandparents, uncles, etc.) see a mental health professional?*
    • Is there alcoholism in your family?*
    • Have any members of your family ever committed suicide?*
    • Do you have any children?*
    • Name and age of children
    • Do you have any brothers or sisters?*
    • Name and age of siblings

    • Social History

    • Are you currently employed?*
    • Are you having problems related to your present job, with others workers or supervisors?

    • Military History

    • Have you been in the Military?*

    • Legal History

    • Have you ever been arrested?*
    • Do you have any legal problems?*

    • Medical History:

    • Are you on medication for a medical condition (ex: insulin, heart pills, seizure medication)?*
    • Have you had any surgeries?*
    • Have you ever had any of the following symptoms or difficulties?*

    • Summery

    • Patient Bill of Rights, Confidentiality and Treatment Form  
    • I have received a copy of the Patient Bill of Rights and Treatment Information, and have been given an opportunity to review it.  *
    • Notice of Privacy Practices 
    • I have received a copy of the Notice of Privacy Practices, and have been given an opportunity to review it. *
    • Authorization For Release Of Healthcare Info Primary Physician 
    • *
    • *

    • Purpose: Coordination of treatment.

      I hereby authorize the release of the above information from my record. I understand that the information to be released from my record is confidential and protected from disclosure. I also understand that I have the right to cancel my permission to release information at any time before it is released. I also understand that my consent to release information will expire:

    • Patient Signature*
    • Date Signed*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Use of E-mail Authorization 

    • Use of E-mail Authorization

      Many patients find it convenient and helpful to communicate with me by e-mail. While I welcome such communications, due to the inherent risks involved in e-mail use, it is important to understand the following:

    • *

    • Patient Signature*
    • Date Signed*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Photo ID 
    • I will provide my photo ID in the following manor*

    • Please provide a copy of a valid photo ID

      Upload - scan and upload using the "Browse Files" button below

      Fax to: 716-633-6902

      Mail to: Nike Carli, LCSW-R 
      5500 Main Street, Suite 259
      Williamsville, New York 14221                                                   
    • Browse Files
      Cancelof
    • Insurance Card 

    • Please provide a copy of your insurance card if applicable

      Upload - scan and upload using the "Browse Files" button below

      Fax to: 716-633-6902

      Mail to: Nike Carli, LCSW-R 
      5500 Main Street, Suite 259
      Williamsville, New York 14221                                                   
    • I will provide my insurance card in the following manor*
    • Browse Files
      Cancelof
    • Submit 
    •   
    • Should be Empty: