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 and Adolescent Forms (Up to Age 17)​

• Authorization for Release of Information

• Adult Contact Form

• Attendance Policy

• Telehealth Consent

• Client Rights and Responsibilities

• Parental Consent for Treatment of a Minor

• Email and Text Consent

• Fee Agreement

• Youth Contact Form

• Primary Care for Release of Information

• Doxy.me Letter to Clients

• HIPAA Policy​​

• The CAGE Questionnaire for Adolescents Age 12 and Over

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Adult Forms (Ages 18+)

• Adult Contact Form

• Attendance Policy

• Telehealth Consent

• Client Rights and Responsibilities

• Authorization for Release of Information

• Email and Text Consent

• Fee Agreement

• PRIMARY CARE PHYSICIAN – Release of information

• PHQ-9

• CAGE

• GAD-7

• Doxy.me Letter to Clients

• Crisis Resources

• HIPAA Policy