WNY Psychotherapy Services



ADULT INTAKE FORM - WNY Psychotherapy Services Adult Intake Form - 18 Years and Up

IMPORTANT NOTE:  This form below DOES NOT take the place of your "New Patient Packet Forms" that are filled in for your initial appointment.  You can download online by going to your assigned provider page once intake schedules your appointment to print and fill in the forms before your appointment or please arrive 30 minutes before your appointment to receive the required paperwork to be filled in before your initial visit.  Thank you!  


Please fill in at least one phone number above where we can reach you.

Monday AM Monday PM
Tuesday AM Tuesday PM
Wednesday AM Wednesday PM
Thursday AM Thursday PM
Friday AM Friday PM
Saturday AM
Abuse/Domestic Violence Issues Behavioral Problems
Communication Problems Depression
Grief & Loss Low Self Esteem
Marital/Relationship Issues Posttraumatic Stress Disorder
Stress Transitions (divorce, job loss, empty nest)