Forms

Dear Patient,

In the directory below, you will find several forms and questionnaires that we will need you to complete either prior to the first session or by the completion of the initial appointment.

Below you will find the following to download and view for your convenience:

  • Adult Packet

  • Child Packet

Included in the packets above are the following individual forms:

  • Patient Registration Form

  • Review & Consent Form

  • Payment Responsibility Policy

  • Missed Appointment Policy

  • Request to Release Records

  • Child Behavior Checklist (Child Packet Only)

  • Adult Behavior Checklist (Adult Packet Only)

  • Guest in Session Form

  • Payment Option Form (Beginning January 1, 2018)

  • Therapy Dog In Training Policy Form (Beginning August 2018)

Please complete these forms to the best of your ability. In addition, the following items will be helpful if available:

  • A copy of IEP (Individualized Education Program)/504 (if applicable)

  • A copy of any previous reports and/or summaries by previous psychologists/therapists

  • A copy of any previous psychological evaluations

All the above information will be vital in helping us fully understand you and help us to guide your treatment. Please contact our office if you have any further questions or concerns.

Sincerely,

Dr. Michael Pica, Dr. Tanya Gluzerman, Dr. Olesia Shalayska, Dr. Anastasia Maravelias, Dr. Morgan Pappas, Dr. Carolyn Werneke, Ms. Clare Mazurkiewicz, Ms. Christine Creighton, & Chomsky


When Printing forms at home, please make sure PRINTER SETTINGS ARE ON SINGLE PAGES, NOT "DUPLEX". FORMS NEED TO BE FILED INDIVIDUALLY AND CANNOT BE DOUBLE-SIDED.

 

FULL PACKETS:

Adult Packet

Child Packet

 

INDIVIDUAL FORMS:

Adult Behavior Checklist

Child Behavior Checklist

Guest In Session Form

Letter Policy

Missed Appointment Policy

Patient Registration Form

Payment Responsibility Policy

Request to Release Records

Review and Consent

Payment Option Form

Therapy Dog In Training Policy Form