Psychology Associates of Brevard

Psychology Associates of BrevardPsychology Associates of BrevardPsychology Associates of Brevard
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Psychology Associates of Brevard

Psychology Associates of BrevardPsychology Associates of BrevardPsychology Associates of Brevard
  • Home
  • Services
  • New Patients
  • Our Team
  • Telehealth
  • Forms
  • Contact Us

Patient Forms

Please download the appropriate form(s), completed, and then return via email to secure@psychologyassociatesofbrevard.com 

New Patient Request Form (docx)

Download

New Patient Request Form (pdf)

Download

New Patient Paperwork (docx)

Download

New Patient Paperwork (pdf)

Download

Medication Request Form (docx)

Download

Release of Information (docx)

Download

Release of Information (pdf)

Download

Authorization to Share Chart Form (pdf)

Download

Dr. Ferro's Intake Form (docx)

Download

Psychiatric Mental Health Intake Form (docx)

Download

2025 Patient Update (pdf)

Download

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 2024

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! 

New Patient Request

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  • Services
  • New Patients
  • Our Team
  • Telehealth
  • Forms
  • Contact Us

2025 Update

 Please complete the update form and return to:  secure@psychologyassociatesofbrevard.com

Without it,  you will be considered SELF PAY

This is a requirement to allow us to file your insurance. The patient must complete and sign a form that updates address, account details and insurance information.  

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