Contact Us 83 E. Main St. Bay Shore, NY 11706 P: 631.666.5067 F: 631.665.41211735 N. Ocean Ave. Suite D Medford, NY 11763 admin@butterflylcswpc.com Please fill out the form below and an associate from Butterfly will contact you. Form New Client Information Form Date * MM DD YYYY Name * First Name Last Name Home Phone * (###) ### #### Cell Phone * (###) ### #### Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Preferred Language * Preferred Treatment method * In person Phone Telehealth Preferred Office Location Bay Shore Medford Port Jefferson Referred to Our Office By Parent Name (If Under the Age of 18) First Name Last Name Parent Home Phone (###) ### #### Parent Cell (###) ### #### Caregiver's Name( If Applicable) First Name Last Name Caregiver's Home Phone (###) ### #### Caregiver's Cell Phone (###) ### #### Reason(s) For Treatment/Notes * Insurance Co. * Name of Insurance Holder * First Name Last Name Date of Birth of Insured * MM DD YYYY Address of Insured * Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance ID # * Group # Provider Phone (###) ### #### Time Selection 1 * Please pick 3 time availabilities Mon Morning Mon Early Afternoon Mon Late Afternoon Mon Evening Tues Morning Tues Early Afternoon Tues Late Afternoon Tues Evening Wed Morning Wed Early Afternoon Wed Late Afternoon Wed Evening Thurs Morning Thurs Early Afternoon Thurs Late Afternoon Fri Morning Fri Early Afternoon Fri Late Afternoon Fri Evening Sat Morning Sat Early Afternoon Sat Late Afternoon Sat Evening Sun Morning Sun Early Afternoon Sun Late Afternoon Sun Evening Time Selection 2 * Mon Morning Mon Early Afternoon Mon Late Afternoon Mon Evening Tues Morning Tues Early Afternoon Tues Late Afternoon Tues Evening Wed Morning Wed Early Afternoon Wed Late Afternoon Wed Evening Thurs Morning Thurs Early Afternoon Thurs Late Afternoon Thurs Evening Fri Morning Fri Early Afternoon Fri Late Afternoon Fri Evening Sat Morning Sat Early Afternoon Sat Late Afternoon Sat Evening Sun Morning Sun Early Afternoon Sun Late Afternoon Sun Evening Time selection 3 * Mon Morning Mon Early Afternoon Mon Late Afternoon Mon Evening Tues Morning Tues Early Afternoon Tues Late Afternoon Tues Evening Wed Morning Wed Early Afternoon Wed Late Afternoon Wed Evening Thurs Morning Thurs Early Afternoon Thurs Late Afternoon Thurs Evening Fri Morning Fri Early Afternoon Fri Late Afternoon Fri Evening Sat Morning Sat Early Afternoon Sat Late Afternoon Sat Evening Sun Morning Sun Early Afternoon Sun Late Afternoon Sun Evening Name of Staff Person Completing Form (BUSINESS OFFICE ONLY) Date (BUSINESS OFFICE ONLY) FOLLOW UP NOTES ( BUSINESS OFFICE ONLY) Thank you for telling us about yourself. We will be in touch soon.-Butterfly LCSW PC For Career Opportunities please contact Danielle at dweidt@butterflylcswpc.com
