Intake Form

Best Time(s) of Day for call back

Best Day(s) of Week for callback

Patient is: *

New Patient
Returning Patient

Patient Name *

First

Middle

Last

Person Filling Out Form *

First

Middle

Last

Are you the patient? *

Yes (please skip down to Patient Information below)
No (go to next item)

Are you a custodial parent?

Yes (go to next item)
No (Please call us to complete this intake 716-836-9460, ex 205)

If Yes, do you have Sole or Joint custody?

Sole
Joint

Patient Information - Patient Age *

Pt. DOB *

Pt. Gender *

Male
Female
Non-binary/genderqueer
Prefer not to specify

Preferred pronoun(s)

SSN

Address *

City *

State *

Zip *

Primary Phone *

Secondary Phone

Email Address *

Primary Care Physician

Who referred you to FCA?

Previous Mental Health Diagnosis? *

Yes
No

If yes, please list primary diagnosis

Previous MH Treatment? *

Yes
No

If yes, please list provider's name and dates

Previous Psychiatric Medications? *

Yes
No

If yes, please list medication name(s) and dates

Current Symptoms

Other Problems (not listed above)

Why are you seeking counseling? *

Please describe in detail

Is the problem related to alcohol or substance abuse? *

Yes
No

Have you received drug or alcohol treatment in the past?

Yes
No

If Yes, where did you receive this treatment?

Would you like to use your health insurance? *

Yes (Complete the insurance section)
No

If No would you like to:

Self-Pay
Use Out of Network Benefits? (If so, please list your insurance information below)

Insurance Company

ID Number and Suffix

Subscriber's Name

Subscriber's Employer

Subscriber's DOB

Subscriber's Relationship to Patient

Group Number

Provider Services Phone #

What type of treatment would you like? *

Therapist Preferences? (please note this is only a preference and not a guarantee)

Please list all time ranges-days when you are available for an appointment *

The more options you provide, the better the chances of getting you in quickly

Any objections to receiving mail / email / phone calls from FCA? *

Yes
No

If yes, explain

Are you willing and able to work with your therapist: In Person at the FCA office? *

Yes
No

On Line? (through your PC, Laptop, Tablet or Smartphone via Video teletherapy) *

Yes
No

By telephone? (landline or smartphone--via Audio teletherapy- no video-just talking)? *

Yes
No

Which manner of working with your therapist do you strongly prefer? *

In Person? (with your therapist at their FCA office)
Video-teletherapy? Using your PC, Laptop, Tablet, or Smartphone
Audio teletherapy? (Using your regular or smartphone)

Please Note: you must cancel a scheduled session at least 48 hours in advance to avoid all fees. There will be a Late Cancellation Fee ($65.00) for appointments cancelled without at least 48-hours’ notice. There will be a Missed Appointment fee ($85.00) for appointments which are missed without any cancellation notice. These fees are not billable to your insurance company. *

I acknowledge that I have read and understood this Late Cancellation/ Missed Appointment Fee Policy and realize that all fees and copays are my responsibility and are due in full at the time of service.

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