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.

Linda Aidala, Ph.D. Donna Bingham, LCSW Anthony Bongiovanni, Ph.D.
Sally Briggs, Ph.D. Barbara Christman, LCSW Annie Coburn-Kane, LCSW
Erin Cornelius, Ph.D. Matthew Davis, LCSW Angelina Delgosha, LCSW
Scott A. Gee, LCSW-R Mary Jo Gervase, LCSW Mackenzie Halker, LCSW
Julie Kramer, LCSW Marlene Longdon, PMHNP-BC Joe Monaco, MSW, LCSW
Vicki Murphy, PMHNP-BC Linda Nash, Ph.D. Bruce Pace, Ph.D.
Tracey E. Pay, LCSW John Perak, LSCW David Pratt, Ph.D.
Sarah Rowland, Ph.D. Jennifer Sands, Psy.D Russell Shefrin, Ph.D.
Rachel Schladebeck, LCSW Nancy Skelton, LCSW Wendell Wild, LCSW
Joseph Zannoni, LCSW
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)