PDF · 2 pages
New Patients · Shelton, Connecticut
Patient forms.
Ready for your visit.
Complete your assigned forms online through Jane, or download paper forms to print and bring with you. Choose the option that works best for you.
Online option
Complete forms
through Jane.
Jane requires you to sign in or create a patient account to complete intake forms online. Use the intake link sent by our office, or sign in to our Jane patient portal and look for your assigned forms under Intake Forms.
Creating an account by itself does not mean your forms have been assigned. If you do not see your forms or need a new invitation, call our office.
Open Jane Patient Portal ↗Print at home
Download your paper forms.
Please download all three forms. The intake form has two pages; the treatment consent and HIPAA acknowledgement each have one page.
PDF · 1 page
Treatment Consent
PDF · 1 page
HIPAA Acknowledgement
Print on standard letter-size paper (8½ × 11 inches). Bring the completed forms to your visit. If you have questions about a consent or acknowledgement, leave that section for discussion with our staff before signing.
Before you arrive
A little preparation.
A smoother visit.
Have your medication list and any relevant records available when completing your intake. Please bring your paperwork with you rather than sending completed health forms through the website contact form or ordinary email.
Need help with your forms?
Call our office for help finding your Jane invitation or preparing your paperwork.
(203) 922-92772 Trap Falls Road, Suite 208
Shelton, CT 06484