Client Forms

Client Forms

Before Your First Appointment

There are multiple forms that need to be filled out and brought with you to your first appointment, as well as your insurance card and photo ID, which will be photocopied for our billing records. Please give the completed forms to our business staff at the front desk when you arrive.

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Northeast Youth & Family Services would like to thank you in advance for choosing our agency for your health care needs. It is our pleasure serving you.

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Child Forms (Up to Age 10)

• Client Information Form

• Child Form – Parental Consent Release Information

• Client – Rights and Responsibilities

• Doxy.me Letter to Clients

• Fee Agreements

• Required Signatures

• Telehealth OMH Crisis Procedures

• HIPAA Policy NYFS Privacy Policy

• Informed Consent for Telemedicine Services

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Adolescent Forms (Ages 11-17)

• Parental Consent for Treatment of a Minor

• Primary Care Release of Information

• Adolescent Information Form- (To be filled out by adolescent)

• Client Information Form (to be filled out by parent/guardian)

• Strengths and Difficulties Questionnaire – Parent Guardian

• Strengths and Difficulties Questionnaire – Student

• The CAGE Questionnaire for Adolescents

• Child Form – Parental Consent Release Information

• Client – Rights and Responsibilities

• Doxy.me Letter to Clients

• Fee Agreements

• Required Signatures

• Telehealth OMH Crisis Procedures

• HIPAA Policy NYFS Privacy Policy

• Informed Consent for Telemedicine Services

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Adult Forms (Ages 18+)

• PRIMARY CARE PHYSICIAN – Release of information

• CLIENT INFORMATION FORM

• PHQ-9

• World Health Organization Disability Assessment Schedule

• Client – Rights and Responsibilities

• Doxy.me Letter to Clients

• Fee Agreements

• Required Signatures

• Telehealth OMH Crisis Procedures

• HIPAA Policy NYFS Privacy Policy

• Informed Consent for Telemedicine Services