Welcome Information and Intake Form

Thank you for contacting our program for services.  This form is to be completed by the person 18 years or older, who is scheduled for an appointment with our program.  If the person scheduled is under 18 years old, this form must be completed and signed by the parent or legal guardian of the minor.

Please complete, sign and submit the form below prior to your scheduled appointment.  If you have any questions or concerns, please reach out to C&FS EAP at 716-681-4300.  This form may not be reviewed for up to 2 business days.  If this is an emergency, please contact emergency services by dialing 911.  If you are seeking mental health support and would like to speak to a counselor immediately, please call 716-681-4300 and press option 2, C&FS EAP is available.

You may review C&FS information and HIPAA Policy here.

Intake Form

"*" indicates required fields

Name of person scheduled for services with our program.
Please provide this information for the purpose of understanding our service users better. We will use this de-identified data to modify options and reflect the community to improve services.
Please let us know how you would like us to refer to you while providing services.
We are able to accommodate providing services in multiple languages. If needed, please let us know if you are requesting interpretation services and your preferred language. This will allow us to plan and serve you to the best of our abilities.
Please provide an email that we can use to communicate with you.
I give permission to send unencrypted emails for appointment reminders only and encrypted emails for all other private communications.
Please provide the best phone number for us to reach you.
I give permission to send unencrypted text messages for appointment reminders only.
I give permission to call this number when needed and to leave a message on voicemail. *
Please identify a person we may contact in the event of an emergency. Please share the name, phone number and the nature of your relationship.
Date of Birth
Tell us the name of the organization you or your household member is affiliated where you receive the benefits of our program.
How did you hear about our program?
What would you like to accomplish by meeting with a counselor?
Please check all that apply and explain below:
Please explain any concerns you checked above. *
For the period of the past 30 days, please total the number of hours your personal concern caused you to miss work. Include complete eight-hour days and partial days when you came in late or left early.
My personal problems kept me from concentrating on my work.
I am often eager to get to the work site to start the day.
So far, my life seems to be going very well.
I dread going into work.
Type Full Name