Forms | North Shore Children's Healthcare

Office Forms

Available To Download at Your Convenience

Annual Input

Please fill out these forms once per year if you are already a patient

New Patients

Please fill out these forms if you are a new patient

Behavioral Health

Please fill out whichever form(s) are applicable

NY State Schools

Forms related to NY State Schools

HIPAA Agreement

Patient Privacy Agreement
Healthix Consent

Authorization to access patient health information from NYS health exchange
Family Demographic Form

Complete one form per family
Family History Form

Complete out one form per family
Patient Demographic Form

Complete one form per patient
Patient History Form

Complete one form per patient

Record Release Form

Authorization to send and receive medical records to and from other providers
HIPAA Agreement

Patient Privacy Agreement
Healthix Consent

Authorization to access patient health information from NYS health exchange
Family Demographic Form

Complete one form per family
Family History Form

Complete out one form per family
Patient Demographic Form

Complete one form per patient
Patient History Form

Complete one form per patient

PHQ9 Modified for Teens

Questionnaire for despression screening
SCARED Screen

Screen for Child Anxiety Related Disorders
CRAFFT Screen

Screening tool for adolescent substance abuse
ADHD Forms

Includes a self-report checklist, parent informant form and teacher informant form

New York State Schools Health Examination Form

Health Examination form required by NY state schools. Please fill out one form per student