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

• Parental Consent for Treatment of a Minor

• Strengths and Difficulties Questionnaire

• Primary Care for Release of Information

• Required Signatures

• Income Survey

• Mail Survey

• Fee Agreement

• Consent for In-Person Services

• Consent for Telehealth Services

• Crisis Procedure for Outpatient Services

• Client – Rights and Responsibilities

• Crisis Resources

• Notice of Privacy Practices

• Doxy.me Letter to Clients

• Fee Agreement

• Telehealth OMH Crisis Procedures

• HIPAA Policy NYFS Privacy Policy

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Adolescent Forms (Ages 11-17)

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

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

• The CAGE Questionnaire for Adolescents

• Strengths and Difficulties Questionnaire – Parent Guardian

• Strengths and Difficulties Questionnaire – Student

• Parental Consent for Treatment of a Minor

• Primary Care Release of Information

• Required Signatures

• Fee Agreement 2022

• Income Survey

• Mail Survey

• Consent for In-Person Services

• Consent for Telehealth Services

• Crisis Procedure for Outpatient Services

• Crisis Resources

• Notice of Privacy and Client Rights

• Parental Consent for Treatment of a Minor

• Doxy.me Letter to Clients

• Telehealth OMH Crisis Procedures

• HIPAA Policy NYFS Privacy Policy

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Adult Forms (Ages 18+)

• PRIMARY CARE PHYSICIAN – Release of information

• CLIENT INFORMATION FORM

• PHQ-9

• CAGE

• GAD-7

• World Health Organization Disability Assessment Schedule

• Client – Rights and Responsibilities

• Consent for In-Person Services

• Consent for Telehealth Services

• Income Survey 2022

• Mail Survey 2022

• Doxy.me Letter to Clients

• Fee Agreement 2022

• Required Signatures

• Crisis Procedures for Outpatient Services

• Crisis Resources

• Notice of Privacy and Client Rights

• HIPAA Policy NYFS Privacy Policy