New Patient Forms

NEW PATIENTS ONLY:

ADMINISTRATIVE FORMS

If you are a new patient of Suffolk Cognitive Behavioral, PLLC, you can print and fill out these forms at home, prior to your first appointment.  On the day of your first appointment do remember to bring them in and simply give them to your therapist.

Federal privacy and treatment guidelines require that all patients fill out HIPPA paperwork. If you would like to read, print out and fill these forms out at home, click the links below. Four separate HIPPA documents are included.  Forms 1, 2 & 3 should be printed, signed and brought into the office on your first session.  Form #4 only needs to be read, print only if you want your own copy for your records.

1. Patient Address Form (Print, read, sign & bring to office)
2. HIPPA  Privacy Agreement (Print, read, sign & bring to office)
3. HIPAA  Agreement Signature (Print, read, sign & bring to office)

4. Patient Agreement – Read Only – Do not print

Information Release Form (if you would like to grant permission to your SCB therapist to speak with and release information to any prior mental health professional or physician, print and sign this form, bring it to your SCB therapist)

*All of the forms noted above should only be used if you have an appointment with SCB and with explicit permission of SCB staff.  Do not reproduce or distribute for any other purpose without express permission.

Contact

Contact us to make your next appointment today or call us at:
Long Island Offices - 631–696-2896
Brooklyn Offices - 347-687-6353

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