NEW PATIENT INTAKE

Let’s Get Started

Complete the form below to begin your care journey. It takes about 2 minutes, and our team will contact you to schedule your appointment.

About You

First Name

Last Name

Date of Birth

Preferred Contact

Mobile Phone

Home address

Street address

Apt / unit

City

State

Zip/Postal Code

What brings you in

How you'll pay

Use my insurance Private pay (self-pay)

Payer / carrier

Member ID

Group #

Insurance card — front

Insurance card — back

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Please Note: We Do Not Pursue any Disability Claims and We Do Not Perform Therapy only Medication Management Evaluations. All New Patients are Reviewed for Insurance Eligibility. Patients Consent to Authorizing the Practice to Review any Medications on New York State Prescription Monitoring Program and We Have a Right to Refuse any Patient on Controlled Substances without a Clinically Legitimate Use as Determined by Clinicians. *