Before receiving care as a patient of DBT Psychological Services of Long Island, we encourage you to fill out the proper form(s). For your convenience, have these available online in PDF format for you below. These forms are created for you as the patient so that you can understand your rights and responsibilities.
Patient Forms
Adult Questionnaire
The Adult Questionnaire form has been designed to provide our staff with the necessary information before your first visit. We provide this so we can offer the most productive experience. We always want to use our time together wisely. When you’re filling out this form, feel free to add any additional information that you think could be helpful to us in understanding your situation. All information provided by you is strictly confidential and will not be released to anyone without your written request.
Child Adolescent Questionnaire
The Child Adolescent Questionnaire is to be completed by the parent or guardian. This form has been designed to provide necessary information to our staff before our initial conference in order to make the most productive and efficient use of our actual time together. As you complete this form, please feel free to add any additional information which you think may be helpful to us in understanding your child. All information provided by you is strictly confidential and will not be released to anyone without your written request.
HIPPA Consent Form
The Health Insurance Portability & Accountability Act of 1996 requires that health care providers give patients a copy of the office Notice of Privacy Practices and make a good faith effort to obtain an acknowledgment of receipt of the same. The HIPPA form serves both as a tool to help educate you on your rights as a patient and to allow you to choose who you would like to share your health information with. At DBT Psychological Services of Long Island, It is our goal to treat each patient as a priority, to respect their personal privacy and to protect their interests.
Patient Contract
The patient contract form is similar to the common new patient form you fill out when you visit a physician for the first time. We ask our patients to fill this out before treatment so we can gather the necessary information including but not limited to; health insurance, emergency contact, primary care doctor, any current medications, and your confidentiality agreement. We want you to know, your treatment at DBT Psychological Services of Long Island is kept in the strictest of confidence.
Medicare Private Contract
Dr. Kim Lehnert has opted out of Medicare. If a Medicare beneficiary wishes treatment from Dr. Lehnert, the beneficiary will be asked to sign a contract in which they agree to forego Medicare benefits and instead pay Dr. Lehnert out of pocket. See private contract.
Questions?
If you have any further questions about these forms or questionnaires, please feel free to contact us at (631) 828-2082. If we’re not available at the time of your call, please leave a message with your name and contact information so that we can return your call within 24 to 48 hours. Or fill out our contact form here.
