New patient forms

Save time and complete your new patient paperwork before your appointment!

OnPatient Portal

Use the link sent to your email to sign up for our OnPatient Portal. If you have not received this invite, please contact the office. Once logged in, click on your appointment and click “check in”. Here, you can complete all of the necessary forms.

Consent Forms

Complete our consent forms prior to your appointment to save time! Use the buttons below to complete your form and they will automatically be sent to us. Or, if you prefer, use these links to download, print, and complete your forms ahead of time. Just bring your completed forms to your appointment.

Download: Consent to Release Information Form (PDF)

Download: Child Medical Consent Form (PDF)

Consent to Release Confidential Information

By completing this form, you are authorizing the disclosure and/or release of individually identifiable health information as outlined below consistent with Federal law concerning the privacy of such information. All requested information must be provided for authorization to be valid.

Client Name

First Name

Last Name

Date of Birth

YYYY

Therapist/Provider

The therapist/provider listed above is authorized to:

Check all that apply

Release or disclose records and/or information to

Obtain or use records and/or information from

Mutually discuss records and/or information

This information should only be released to:

Fax Number

(###)

###

####

Specific information to be released/obtained

Release/obtain only the following records or type of information:

Please specify if any information is to be excluded

If none, enter N/A

By typing your name below, this authorization shall become effective immediately and will expire upon discharge unless otherwise requested by the client.

Enter your full name

I am the:

Child Medical Consent Form

Authorization and Treatment

Complete the fields below to give permission to another adult to make medical decisions regarding my child while under the care of New Day Therapy.

Name of Parent/Guardian

First Name

Last Name

Name of Proxy

The person you are giving permission to

First Name

Last Name

Relationship to Proxy

New Day Therapy Provider Name

I give consent for the following areas:

Appointment scheduling / rescheduling

Medication decisions / changes

Child Information

Name of Child 1

First Name

Last Name

Date of Birth - Child 1

YYYY

Name of Child 2

First Name

Last Name

Date of Birth - Child 2

YYYY

Limitations

Identify any limitations on the kinds of medical services for which this authorization is given

None

Limitations described below

Limitations, if any

By typing your name below, you consent to the information provided. Consent will expire upon discharge unless otherwise requested by patient.

Enter your full name

Parent Vanderbilt
PHQ 9 for Adolescents
PHQ 9
Safety Plan
Screen for Child Anxiety Related Disorders (SCARE)
School Refusal Assessment
Sleep Log
Social Interaction Anxiety Scale (SIAS)
Social Phobia Scale
Spence Anxiety - Child
Suicide Risk Screening
Taylor Manifest Anxiety Scale (TMAS)
Teacher Vanderbilts
The Penn State Worry Questionnaire (PSWQ)
Young Mania Rating Scale (YMRS)
Zung Self-Rating Depression Scale (SDS)

New patient forms

OnPatient Portal

Consent Forms

Forms to download and print