Intake forms

1. Child/Adolescent Treatment Agreement

2. Child/Adolescent Psychosocial Questionnaire

3. Adult Treatment Agreement

4. Adult Psychosocial Questionnaire

The Billing Schedule form must be signed by the parent, guardian, or adult patient and submitted to our office before we can schedule an appointment. The signed Billing Schedule form can be emailed here.

Behavioral Health Associates of Western New York

ACCEPTANCE OF PATIENTS AND APPOINTMENT SCHEDULING POLICY

Our office staff recently received notice that you would like to schedule an initial assessment

with our psychiatrist. Our policy for accepting patients into treatment and scheduling an initial

appointment requires a pre-admission screening process. This is a simple process in which the

patient/parent/guardian can download the pre-admission packet from our website,

including (1) the Treatment Agreement and Patient Responsibility Form, (2) the Billing/Fee Schedule,

and (3) the Psychosocial/Health Screening Questionnaire. These forms must be read and reviewed

carefully, completed, signed, dated where appropriate, and returned to our office

promptly by email , mail, or in person. Our physician will review the information given, and if

you/your child is accepted for treatment, an initial intake/assessment will be scheduled. An

appointment/confirmation letter will be sent to you with the agreed-upon date/time of you/your

child’s appointment. Please be assured that all information received will be kept strictly

confidential. Our policy is to accept patients that we feel are appropriate and will benefit from

our treatment services.

We appreciate your cooperation,

Sincerely,

Ronald A. Cooke, MD

*** In order to provide optimal service and quality time with patients Dr. Cooke no longer takes most insurances. He does accept Highmark and BC/BS traditional insurance, as they do allow ample time to be spent with his patients. We will provide an itemized receipt for each visit for possible reimbursement from your insurance company as an out-of-network benefit. Please contact your insurance company regarding reimbursement for out-of- network providers.

Ronald A. Cooke, MD

Phone: 716-748-7474

Fax: 716-748-7475

Email: Behavioralhealthofwny@gmail.com

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