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Children & Adolescents
Adults
Education
ABA
Intake Form
Patient Information
Assigned Sex at Birth
Male
Female
Current Gender Identity
Male
Female
Gender Diverse
The patient is:
Child (Under 18)
Adult (18 and over)
County
Oneida
Herkimer
Madison
Onondaga
Lewis
Other
What county?
Preferred Office Location
Utica
Syracuse
Rochester
Responsible Party Information
Required
Check here if the patient is the responsible party.
Relationship to the patient
Biological Mother
Biological Father
Adoptive Mother
Adoptive Father
Step Mother
Step Father
Grandmother
Grandfather
Aunt
Uncle
Husband
Wife
Spouse
Legal Guardian
Self
Other
Phone 1
Type
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Phone 2
Type
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Phone 3
Type
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Second responsible party.
Optional
Relationship to the patient
Biological Mother
Biological Father
Adoptive Mother
Adoptive Father
Step Mother
Step Father
Grandmother
Grandfather
Aunt
Uncle
Husband
Wife
Spouse
Legal Guardian
Self
Other
Phone 1
Type
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Phone 2
Type
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Phone 3
Type
Home
Work
Cell
Is it alright to leave a message?
Yes
No
Referral Information
Please Choose One
Self-referred
Referred by Provider
Other
Concerns and Goals
What is your goal for completing an evaluation with us (check all that apply)?
Engage in treatment for my child
Apply for other programs
Obtain school services
Obtain a medication recommendation
Obtain a referral for another treatment provider
Other
Check all that apply.
Explain 'Other' Goals
If you are interested in treatment appointments, please list your available days and times.
If there are not currently times that match your availability, would you be interested in being placed on a wait list?
Yes
No
Are you seeking a custody evaluation?
Yes
No
Was this evaluation court ordered?
Yes
No
Patient History
Has your child ever been diagnosed with any mental health, behavioral or emotional disorders?
Yes
No
Please list all diagnoses.
Is your child currently seeing a mental health provider?
Yes
No
Please enter the current mental health provider.
Has your child ever received mental health treatment with someone other than the provider listed above?
Yes
No
Please enter your child's past mental health provider and when received.
Is your child currently taking any stimulant medications?
Yes
No
Please enter your child's stimulant medications.
Is your child currently taking any other medications for mental health, behavioral health, or emotional problems?
Yes
No
Please enter your child's medications.
Does your child or has your child ever seen a psychiatrist?
Yes
No
Please list name(s) and when last seen.
Does your child currently see, or has your child ever seen a neurologist?
Yes
No
Please list name(s) and when last seen.
Do you suspect that your child has any of the following?
Autism
ADHD
Dyslexia
Depression
Anxiety
Intellectual Disability
Check all that apply.
Has your child had any of the following?
Head injury/concussion
Loss of consciousness
Seizure (not due to fever)
Lead poisoning
Brain infection
Significant premature birth
Very low birth weight
Exposure to cigarettes, drugs, alcohol, or prescription medication during pregnancy
Loss of oxygen (during birth or otherwise)
Patient History
Have you ever been diagnosed with any mental health, behavioral or emotional disorders?
Yes
No
Are you currently seeing a mental health provider?
Yes
No
Have you ever received mental health treatment with someone other than the provider listed above?
Yes
No
Are you currently taking any stimulant medications?
Yes
No
Are you currently taking any other medications for mental health, behavioral health, or emotional problems?
Yes
No
Do you or have you ever seen a psychiatrist?
Yes
No
Do you or have you ever seen a neurologist?
Yes
No
Do you suspect that you have any of the following?
Autism
ADHD
Dyslexia
Dementia
Depression
Anxiety
Intellectual Disability
Check all that apply.
Have you ever had any of the following?
Head injury/concussion
Loss of consciousness
Seizure (not due to fever)
Lead poisoning
Brain infection
Significant premature birth
Very low birth weight
Exposure to cigarettes, drugs, alcohol, or prescription medication during pregnancy
Loss of oxygen (during birth or otherwise)
Insurance Information
Check here if you are Self-Pay.
Check here if the patient is the insured
Insured's relationship to patient
Biological Mother
Biological Father
Adoptive Mother
Adoptive Father
Step Mother
Step Father
Grandmother
Grandfather
Aunt
Uncle
Husband
Wife
Spouse
Legal Guardian
Self
Other
Is the patient currently receiving Social Security Disability benefits?
Yes
No
Are you in the process of applying for Social Security Disabilities benefits?
Yes
No
Submit
Optional email address
Send Intake Form