Before Your Visit
Prior to becoming a patient at NCBM all potential patients will be required to complete the appropriate Intake Form(s). Below you will find links that will take you to our online intake forms. This process is fully HIPPA compliant and these forms will be sent to us via a secure portal. This is the preferred method of submitting intake forms to our clinic.
Intake Forms
Complete Online
Download or Print
Intake Forms for Transcranial Magenetic Stimulation (TMS) Only
Forms completed online will be sent to the clinic directly using a HIPPA compliant process.
If forms are completed using the download/print option, then forms can be sent to us via fax at (518) 825-1550, mail at 8 Broad Street, Plattsburgh, NY 12901, or via email at [email protected] (not HIPPA compliant).
Sliding Scale Program
Our clinic is committed to providing care to our community members regardless of ability to pay. If you meet certain income requirements you may be entitled to a discounted fee to see one of our providers. Please see our income requirements here: NCBM Sliding Scale Income Requirements.
If you would like to apply for the sliding scale program please complete this application and return it to one of our staff: NCBM Sliding Scale Application