NYC Psychologist

Initial Information Form

To schedule an initial consultation, please complete, filling in all the requested information, and then submit this form. Dr. Haley will get back to you by email as soon as she can. Please note that due to time constraints and frustration with tag-telephone, Dr. Haley can only respond to you by email so Please be sure that your email address is entered correctly.

First Name

Last Name

Date of Birth

Age

Gender

Street Address

City

State

Zip Code

Phone 1

Phone 2

Mobile

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

Description of Issues

What days of the week and times of each day are you available to meet?

Preferred

Possible

How did you learn about NYC Psychologist?

(Please check all that apply)

Referral from a friend or family member

What is that person's name?

Referral from my doctor or other healthcare professional

Please provide the name of the referring professional.

Via Google or another search engine

Which Search Engine?

From Psychology Today

From Facebook or other social media

From my health insurer

Other

Please describe who or what the other is.

Health Insurance Information

(Note: Health insurance does not pay for coaching.)

If you do not plan to use health insurance to help pay your fees, skip this section. Otherwise, please answer the following:

What company provides your mental health insurance?

Is your health insurer part of Optum or UHC?

Yes

If yes, please answer the following question so that your eligibility and benefits can be ascertained. If you plan to use your insurance benefits, a consultation will not be scheduled until this information is provided.

What is your Insurance Member ID? (The information should be on the back of your health insurance card.)

If your health insurance company is part of Optum, indicate below which part?

UBH

Oxford

Another Component

Please state what other:

Questions

If you have reviewed the information on this website and still have questions, please ask them here:

Questions

** Please check to ensure that you have provided your correct email address in the space provided. Due to time constraints and frustration with tag-telephone, Dr. Haley can only respond to you by email. **

Okay, now, click the send button below and you will be contacted via email, usually by the weekend following receipt of this form, about scheduling a meeting with Dr. Haley.

Please be patient and wait until you arrive at the "thank you" page before leaving this page. Otherwise, your form will not be transmitted. Thanks.