Untitled Document

Date:	First Name:	Last Name:
Phone1:	Phone2:	Email:

Street Address:

City & State:

Zip Code

Date of Birth:

Gender:

Please provide a brief description of the problems that bring you to treatment (e.g., ansiety, depression, relationship problems, achieving or identifying your goals). No more than 2-3 sentences please:

Description of Problems

Hours you are available to be seen:

Preferred: Possible

How did you learn about NYC Psychologist?

Referral from a friend or family member
Referral from your doctor or other healthcare professional
Via Google or another search engine
From Facebook or other social media
From my health insurer's website
Other

Health Insurance Information

Is United Health Insurance (Optum) your mental health insurance provider?
If yes, is your insurer UBH or another component (e.g., Empire, Oxford, Pacifica)?
If another, what other: