Nike Carli,LCSW-R
Licensed Clinical Social Worker
Patient Forms
Whether you’re a new patient preparing for your first visit or a returning patient looking to update your medical information, you’ll find a range of useful forms below. If you need help finding additional information or have questions about any form, please call my office at 716-633-6900
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.
Office Appointment
New Patient Office Visit Forms Packet
Please print and bring the completed forms to your first visit.
New Patient Telehealth Forms Packet
Please print and mail the completed forms prior to your first telehealth appointment
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.
Online form submission coming soon
Printable Forms
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.
Patient Information & History Form
Authorization For Release Of Confidential Information Primary Care Physician
Authorization For Telehealth
Nike Carli,LCSW-R
Licensed Clinical Social Worker
Patient Forms
Whether you’re a new patient preparing for your first visit or a returning patient looking to update your medical information, you’ll find a range of useful forms below. If you need help finding additional information or have questions about any form, please call my office at 716-633-6900
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.
Office Appointment
New Patient Office Visit Forms Packet
Please print and bring the completed forms to your first visit.
Online Form Submission
Online Form Submission
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.
New Patient Telehealth Forms Online Submission
Please note: all the intake forms are in the packet, you do not need to fill out any of the forms below.
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.
New Patient Office Visit Forms Online Submission
Please note: all the intake forms are in the packet, you do not need to fill out any of the forms below.
New Patient Telehealth Forms Packet
Please print and mail the completed forms prior to your first telehealth appointment
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.
Printable Forms
Printable Forms
