Contact We're here to help—contact us today to schedule an appointment or learn more about our services. Patient's Name * First Name Last Name Guardian Name (if applicable) First Name Last Name Patient's Date of Birth * MM DD YYYY Email Address * (Self or Child's Guardian) Email Address of Child (if applicable and child is over 18) Phone Number * (###) ### #### Choose the type of service(s) that you are interested in * (choose all that apply) Clinical Consultation / Assessment Neuropsych Testing Therapy Intensive Therapy program Coaching Professional Consultation Other Choose the location(s) that you are interested in * (choose all that apply) Virtual- patient located in NY State In-Person (Manhattan) In-Person (Brooklyn) In-Person (Home Visits) What is the primary reason why you want to see a doctor? Are you/your child currently demonstrating school avoidance and/or refusal behaviors? * Yes No If yes, please explain. Are you currently working with a therapist or psychiatrist? * Yes No Will anyone (e.g parent, spouse, support worker) potentially be joining your session? If yes, who? * What is the general availability (for the Patient and for Parent/Guardian if applicable) Monday-Saturday? (specify ALL available days/times) * Are you located in New York State? * Note: We are currently only licensed to see patients in NY state. Yes No Would you like to have a 15-minute consultation with our office administrator to answer general questions? Note: We are currently only licensed to see patients in NY state. Yes No Thank you! Your form has been submitted. We will respond soon. HOME CLIENT PORTAL FEEDBACK
