CHILD & ADOLESCENT INTAKE FORM
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. Maryann Antonelli, LCSW-R
Ashley Ausikaitis, Ph.D., NCSP Anthony Bongiovanni, Ph.D.
Sally Briggs, Ph.D. Julie Carlin Kramer, LCSW-R
Erin Cornelius, Ph.D. Matthew Davis, LCSW-R
Angelina Delgosha, LCSW-R Scott Gee, LCSW-R
Mary Jo Gervase, LCSW-R Rachel Gill, LCSW-R
Mackenzie Halker, LCSW-R Kariann Hickein, LCSW-R
Marlene Longdon, PMHNP-BC Joe Monaco, MSW, LCSW-R
Vicki Murphy, PMHNP-BC Linda Nash, Ph.D.
Bruce Pace, Ph.D. Tracey E. Pay, Ph.D.
John Perak, LCSW-R David Pratt, Ph.D.
Sarah Rowland, Ph.D. Jennifer Sands, Psy.D.
Russell Shefrin, Ph.D. Nancy Skelton, LCSW-R
Wendell Wild, LCSW-R Joseph Zannoni, LCSW-R

Please click on the provider you have been referred to.

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ADHD Addiction
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