Child & Adolescent Intake Form

WNY Psychotherapy Services

716-837-6705

Intake form for patients 17 years and younger.

IMPORTANT NOTE: This form below DOES NOT take the place of your "New Patient Packet Forms" that are filled in for your initial appointment. You can download online by going to your assigned provider page once intake schedules your appointment to print and fill in the forms before your appointment or please arrive 30 minutes before your appointment to receive the required paperwork to be filled in before your initial visit. Thank you!

Preferred Office Location:

Orchard Park

Telehealth

Child First Name:

Child Middle Initial:

Child Last Name:

Sex of Child:

Child Date of Birth:

Address:

Address 2:

City:

State:

Zip:

Are you the Legal Guardian?

Yes No

First Name of Legal Guardian:

Last Name of Legal Guardian:

Legal Guardian Relationship to Child

Legal Guardian Date of Birth:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Please place best number to reach you here:

Best time to reach you:

IMPORTANT NOTE: Please expect a call back within 5-7 business days. Please check this box acknowledging you understand our call back policy. Thank you!

INSURANCE CARD - If you can, please upload a photo of your insurance card here. Thank you!

Add file

Please upload a file

Insurance Provider:

Insurance ID#:

Insurance Group #:

Insurance Subscriber Name:

Subscriber Date of Birth:

Subscriber address if different from yours:

City, State and Zip Code:

Subscriber Phone:

Are you covered by any other insurance?

Yes No

If yes, please list additional Insurance Company:

2nd Insurance Company Group #:

2nd Insurance Policy ID#

Was your child referred to a specific provider?

Yes No

If yes, please type in the name of the provider you were referred to:

How did you hear about us?

Comments regarding you schedule:

Other - Please list or explain what you are looking for if there is not an option above that matches your needs.

Additional comments:

Your information will be encrypted.

At WNY Psychotherapy Services, we strive to provide our patients with the best treatment options. As a private mental health treatment organization, we understand what it takes to enhance the emotional health of our patients and their families. Our practice is made up of 20 independent licensed practitioners, each with various areas of expertise. We understand that it is hard to admit when you need help. When you feel as though you are hitting rock bottom and feel like no one is there to help, turn to WNY Psychotherapy Services. Choosing the right supports is an important step in the recovery process. Our mental health therapists can help provide you with a psychological evaluation. By talking to you about your symptoms, thoughts, and feelings, we can gain a better understanding about the things going on in your life and help use that as a baseline on how to begin mental health treatment.

www.wnypsychotherapy.com