New Client Portal

New Client Portal

Welcome!  Please take some time to fill out the forms below.  

Finding out some basic information about you, and what you want us to work on together is a crucial step for us to have a productive and meaningful first session together. Please note your information will be kept private, and will be used for the assessment only.  

Below, you will find the following forms:

It is required for you to submit the forms with required signature prior to our first meeting.  If you have any questions, please feel free to give me a call at 718.404.4627.  

Have not booked your session yet?


Intake Form

Name *
Name
Cell Phone *
Cell Phone
I frequently use text messaging to communicate with my clients, especially to schedule appointments and to do a quick check-ins.
Mailing Address *
Mailing Address
Date of Birth *
Date of Birth
Time of Birth *
Time of Birth
Please enter 0, if unknown.
City, State and Country. Enter n/a if unknown.
Please list your health concerns (physical, emotional, psychological, or spiritual) in order of importance/urgency to you, with the date of onset.
This is your primary goals in your life and health. Please tell me about your wishes and dreams - don't be shy!
Please list any medical history significant to you, with corresponding dates. Please also list any chronic physical or emotional issues. Significance is relative - please list anything that comes to your mind.
Please list your most stressful life events, and the year of occurence
Please describe the current emotional climate of your home
Emergency Contact: Name *
Emergency Contact: Name
Emergency Contact: Cell Phone
Emergency Contact: Cell Phone
Please let me know if you have any spiritual/religious practices, and how important it is to you.