Advance Directives

Planning healthcare, end-of-life care, and more.

Dental Forms

Authorization of Release of Health Information Forms:

Medical Patients

Authorization of Release of Health Information Forms:

New Patients

Opioid Treatment Program (OTP)

Authorization of Release of Health Information Forms:

Outpatient Clinic (Formally FACTS Program)

Authorization of Release of Health Information Forms:

Patient Satisfaction Survey

How Are We Doing?
Please complete our Patient Satisfaction Survey to give us your feedback!

If you would prefer to complete the survey on paper, download the PDF versions below:

If you speak a language other than English or Spanish and need a translator to help you complete the survey, or if you have any questions or concerns, please contact our Patient Engagement Specialist at 518-465-4771, extension 5057.

School-Based Health Centers (SBHC)

A parent or guardian must fill out the form below for their child or children to receive care at any of our School-Based Health Centers (SBHC). Please submit the completed form to the school your child or children will be attending.

Please note: Parents/guardians must complete an updated consent form every year for their child or children to continue receiving care through their SBHC. Please use the form below to update consent.

If you have questions about availability of services for your child or children, please contact Whitney Young Health’s School-Based Health Center program at (518) 465-4771

Sliding Fee Scale Discount

To qualify for Whitney Young Health’s Sliding Fee Scale Discount, please fill out the form below and provide the required documentation listed in the application.

The form and required documentation can be brought in to Registration Staff any of our health center locations or emailed to registration@wmyhealth.org.

Whitney On Wheels (WOW)

Below are the forms you must fill out for yourself or for your child/children to receive medical care on our mobile health unit, Whitney on Wheels (WOW).

Please submit the completed form(s) to the representative of the sites WOW currently visits.

Questions? Please call (518) 465-4771.

WIC (Women, Infants & Children)