Intake form for patients 17 Years & Younger

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!  

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

Please click on the provider you have been referred to.

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Tuesday AM Tuesday PM
Wednesday AM Wednesday PM
Thursday AM Thursday PM
Friday AM Friday PM
Saturday AM
ADHD Addiction
Anxiety Aspergers
Behavioral Issues Depression
Domestic Violence Drug Abuse
Eating Disorders Learning Disabilities
Self Esteem Self Harming
Teen Violence