• Nike Carli, LCSW-R

    Nike Carli, LCSW-R

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

  • New Patient Telehealth 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
    • Telehealth Authorization 

    • I understand that telehealth involves the communication of my behavioral health information in an electronic or technology-assisted format.

      I understand that I may opt out of the telehealth visit at any time. This will not change myability to receive future care at this office. 

      I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.

      I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment isreduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:

      •It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.

      •Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.

      •Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.

      I agree that information exchanged during my telehealth visit will be maintained by Nike Carli, LCSW-R

      I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.

      The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.

      I understand that electronic communication cannot be used for emergencies or time-sensitive matters.

      To the extent permitted by law, I agree to waive and release my healthcare provider and her practice from any claims I may have about the telehealth visit.

    • *
    • Patient Signature*
    • Date Signed*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Photo ID 

    • 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                                                   
    • I will provide my photo ID in the following manor*
    • Browse Files
      Cancelof
    • Insurance Card 

    • Please provide a copy of your insurance card (front & back) 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 
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