Patient Forms
Please download the appropriate form(s), completed, and then return via email to secure@psychologyassociatesofbrevard.com
Explanation of Forms
New Patient Request Form
New Patient Request Form
New Patient Request Form
If you would like to schedule a New Patient Appointment with one of our providers please complete this form and submit to secure@psychologyassociatesofbrevard.com for consideration.
New Patient Paperwork
New Patient Request Form
New Patient Request Form
This is to be completed AFTER you have been scheduled for an appointment with one of our providers. This packet MUST be complete prior to your appointment. If you are interested in scheduling please go to the New Patient Request page for instructions.
Medication Request Form
New Patient Request Form
Medication Request Form
This form is for existing patients who have medications prescribed by a provider in this office. Your provider may charge a $20 fee for this service if requested in between scheduled appointments. This fee will be the patient’s responsibility and is not covered by insurance.
Release of Information
Authorization to Share Chart Form
Medication Request Form
Use this form to request medical records, letters, or other medical related documents. This form should also be filled out prior to a Bariatric Evaluation so that the report is sent to the proper surgeon's office.
Authorization to Share Chart Form
Authorization to Share Chart Form
Authorization to Share Chart Form
Since we have a variety of providers in this office, you may be scheduled with an additional provider. If so, please fill out this form so that the providers can share your information and chart.
Dr. Ferro's Intake Form
Authorization to Share Chart Form
Authorization to Share Chart Form
Dr. Ferro requests that this form is filled out prior to a New Patient Appointment with him.
Psychiatric Mental Health Intake Form
Psychiatric Mental Health Intake Form
Psychiatric Mental Health Intake Form
This form is to be completed prior to your first new patient appointment with Nicolina Demuynck, PMHNP-BC.
Patient Update 2022
Psychiatric Mental Health Intake Form
Psychiatric Mental Health Intake Form
It is required for the patient to complete and sign a form that updates address, account details and insurance information every calendar year.
Here for You.
Interested in scheduling with us? Submit a New Patient Request today!
Copyright © 2022 Psychology Associates of Brevard - All Rights Reserved.
Update 2023
Please complete the update form and return to: secure@psychologyassociatesofbrevard.com
Every calendar year, it is required for the patient to complete and sign a form that updates address, account details and insurance information.
Without it, you will be considered SELF PAY