Intake Form



New patients will need to print and fill out this intake form. Please bring this form to your first appointment; completing this prior to your appointment saves valuable time. To make the process as smooth and efficient as possible, I provide this form in a PDF file right here on my website.


If you have any questions, don't hesitate to contact me.

Intake bio.pdf
Adobe Acrobat document [256.5 KB]

Note: You will need Adobe(r) Reader(r) to view PDF files. If you do not have it, you can download it for free.



Beth Estergomy LCSW

168 Main St

Suite B

Huntington, NY 11743


Phone: 631-896-2884


Or use our contact form.

Office Hours by appointment only

Patient Forms

New patient? Save time and reduce the amount of paperwork you have to fill out at your first visit. I provide the Intake form as a PDF download on the site.

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© Beth Estergmy LCSW