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

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Submit Online.jfif
Submit Online.jfif
Submit Online.jfif

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

Submit Online.jfif

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

Submit Online.jfif
Submit Online.jfif
Submit Online.jfif

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.

Submit Online.jfif

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.

Submit Online.jfif
Submit Online.jfif
Submit Online.jfif
Submit Online.jfif

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.

Submit Online.jfif

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

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For New or Returning Patients

For New or Returning Patients

For New or Returning Patients

For New or Returning Patients

Telehealth  Appointment