Intake Forms

These secure intake forms (top sections below) will help give me a general understanding of your issues and situation in order to give the best care. These forms can be completed online in preparation for our first online video session.

Initial Intake Packet Please Complete These First (all intakes) Intake Face Sheet complete this first Consent for HealtheConnections Informed Consent for TeleMental Health Online Group Therapy Agreement Office Policy on Social Distancing and Covid19 Safety Depression, Anxiety, Stress Scale (DASS-21) 21 questions Suicide Behaviors Questionnaire-Revised (SBQ-R) 4 questions Substance Use Questionnaire (CAGE-AID) 4 questions Adverse Childhood Experiences (ACEs) 10 questions Life Events Checklist (LEC-5) Brief Biosocial Gambling Screen (BBGS) 3 questions Screening Questionnaires (alcohol/substance evaluations only) Drug Abuse Screening Test (DAST-20) 20 questions Alcohol Use Disorders Identification Test (AUDIT) 10 questions Short Michigan Alcoholism Screening Test–Geriatric (SMAST-G) 10 questions Screening Questionnaires (gambling assessments only) DSM-V Pathological Gambling Diagnostic Form 9 questions fillable PDF Brief Biosocial Gambling Screen (3 questions) fillable PDF Problem Gambling Severity Index (PGSI) fillable PDF South Oaks Gambling Screen (SOGS) fillable PDF NORC Diagnostic Screen for Gambling Problems PDF Problem Gambling Chart PDF

Other Assessments (as applicable)

• Adult ADHD Self-Report Scale (ASRS-v1.1) 18 questions
• Personal Health Questionnaire (PHQ-9) 9 questions
• Anxiety Questionnaire (Worry 7) 7 questions
• Generalized Anxiety Disorder (GAD-7) scale PDF
• Michigan Alcohol Screening Test-Alcohol/Drug (MAST-AD) PDF
• Current Opioid Misuse Measure (COMM) PDF
• Edinburgh Postnatal Depression Scale (EPDS) from perinatology.com PDF
• Mood Disorder Questionnaire (MDQ) 15 questions fillable PDF
• Medication, Lifestyle and Mood Logs fillable PDF
• Premenstrual Dysphoric Disorder Symptom Log fillable PDF
• Weight and Lifestyle Inventory (WALI) fillable PDF
• Eating Disorder Questionnaire (EDE-Q 6) fillable PDF
• Sleep Questionnaire fillable PDF

Consent Forms

• Authorization to Consent to Release of Information Pursuant to HIPAA | Reverse
• Consent to Release of Information General purpose for agencies and others
• Consent to Release of Information NYS OASAS Impaired Driver System
• Consent to Release of Information CRJ: courts, probation, parole, etc.
• Consent to Release of Information NYS OASAS & Council on Problem Gambling
• Online Group Therapy Agreement for group therapy participants
• Office Policy on Social Distancing and Hygiene: Informed Consent Concerning Public Health Precautions in Counseling Services During a Pandemic

If you prefer, instead of the above secure forms, prior to your initial appointment you may print this MS Word file containing the same intake packet, complete the forms by hand, and either upload, fax, or otherwise securely transmit them to me. My confidential fax number is 866-428-0282, or you may send encrypted email to tom@choicesmhc.com, or (if the appointment is days away) snail-mail them to:

Choices Mental Health Counseling PLLC
Narrowsburg Union
7 Erie Avenue
Narrowsburg, New York 12764

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For Existing Clients

• Confidential Group Feedback Form for group therapy particpants
• Session Note New York Council on Problem Gambling
• Signature Backup Form Aegis Sciences Corp.
• CMS 1500 generic health insurance claim form fillable PDF
• Health Insurance Opt-Out Form for private pay
• Sullivan County DFS/CWD Attendance and Progress Report fillable PDF
• NYS Mileage Reimbursement Form Medicaid claim for use of personal vehicle PDF
• Consent to Apply for Services with ACCES-VR
• Consent to Release/Obtain Information with ACCES-VR
• Application for ACCES-VR Services fillable PDF (click here for more info.)
• Tobacco, Alcohol, Prescription medication, and other Substance use Tool (TAPS) NIH

Policies and Procedures

• Client Handbook contains Informed Consent and Notice of Privacy Practices, effective June 15, 2017.
• Attendance Policy revised May 11, 2019
• Policy and Procedures on TeleMental Health May 5, 2020 (NYS DFS Guidance)
• Policies and Recommendations on Medical Marijuana effective January 12, 2019, pursuant to NYS PHL § 3360, et seq. and regulations of the NYS DOH
• Social Media Policy revised February 4, 2018 (link to Facebook Page)
• Informed Consent Relative to Managed-Care Medicaid revised January 1, 2018
• Weather Cancellation Policy revised December 26, 2012
• US DOT SAP Statement of Understanding revised January 1, 2018
• Preparations for Pre-Adoption Home Studies revised December 22, 2017
• Urine Drug Screen Policy and Procedure draft dated June 23, 2019
• Website Information and Privacy Policy effective August 13, 2010
• Policy on Caring for Recent Patients of NYS OASAS Treatment Centers effective from April 17, 2000 until October 27, 2013

For Information and Reference

• COVID-19 Self Risk-Assessment questions to ask yourself before going out
• General Information on the Flu from NYS OASAS and DOH [Flu Tracker]
• Clinical Opiate Withdrawal Scale (COWS) flow-sheet for measuring symptoms for opiate withdrawal over a period of time, for reference when seeking admission to inpatient detox or when preparing for buprenorphine/naloxone induction (for patient awareness; scale must be administered by a medical professional) PDF