FMS CHILD & FAMILY EVALUATION AND TREATMENT CENTER
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Intake forms & documents

The following forms should be completed and presented to your therapist at your initial appointment.  If you are unable to print these documents, please notify your provider so that the documents can be made available to you to complete at your initial session- please arrive 30 minutes prior to your scheduled appointment if you need to complete paperwork. 

Insurance coverage information should be obtained by contacting your carrier prior to your initial session.  You should inquire regarding: your plan's participation with your provider, your copay, if you have a deductible, if you need prior authorization for treatment and if you need a referral. 

Services Agreement
File Size: 46 kb
File Type: docx
Download File

Consents/Releases
File Size: 61 kb
File Type: docx
Download File

FMS HIPAA
File Size: 39 kb
File Type: docx
Download File

HIPAA Privacy Summary
File Size: 381 kb
File Type: pdf
Download File

Intake Form- Adult
File Size: 407 kb
File Type: pdf
Download File

Intake Form- Adolescent
File Size: 600 kb
File Type: pdf
Download File

Intake Form- Child
File Size: 446 kb
File Type: pdf
Download File


Our location

6556 East Quaker
Orchard Park, NY 14127
phone: 716.539.9232
fax: 716.539.9230

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