IFQ

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 as soon as she can by email so please be sure that your email address is entered correctly.

Please note that the Initial Consultation is a full session in which your problems are assessed, a diagnosis is formulated, recommendations are provided and is the initial basis for treatment planning. Also, please note that all sessions are remote via video.

Name

First NameLast Name

Email

example@example.com

Age

Date of Birth

Date

Gender

Address

Street Address

Street Address 2

CityState / Province

Postal / Zip Code

Phone 1

Area CodePhone Number

Phone 2

Area CodePhone Number

Mobile

Area CodePhone Number

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

Describe issues

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

Preferred

Possible

How did you learns about NYC Psychologist?

Please indicate all that apply and ignore those that do not.

Referral from a friend of family member

If yes, please provide name

Referral from healthcare professional

If yes, please provide name

Found on Google or another search engine

If answer above is 'another search engine"

which search engine

From Psychology Today

From social media

From my health insurer

Health Insurance Information

Do you plan to use health insurance to help pay your fees?

If you responded "no" to the above question, skip this section.

Otherwise, please answer the following questions.

What is the name of your primary mental health insurance company? Enter name of the company as it appears on your ins card

Is your primary health insurer a part of Optum or UHC?

What is your Insurance Member ID? (This info should appear on your insurance card.)

Do you have secondary or other health insurers besides the primary insurer indicated above?

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

Email Communications

As a sole practioner with no staff, Dr. Haley uses email for almost all communications outside of sessions. Emails from Dr. Haley are essentially to matters such as fees, scheduling and insurance coverage. She does not send emails containing personal informations such as diagnosis, treatment or issues discussed unless you ask her to do so and she agrees.

Most email service do not utilize encrypted email. That means that although unlikely, a third party might be able to access email communications between Dr. Haley and you and read them.

Federal Guidelines require that you consent to the use of email for communicating health information in order for it to be used.

<< Note: If you do not agree to using email communications by checking the box below, Dr. Haley will not be able to work with you and this form will not transmit. >>

I understand the risks of unencrypted email and do hereby give permission to NYC Psychologist (Incorporated as Haley Psychology Services, P.C.) to send me personal health information via unencrypted email. By submitting this form and checking this box, I am consenting to the use of email between Dr. Haley and myself.

** Please check to ensure that you have entered your correct email address in the space provided above so that Dr. Haley's response will reach you. **

Okay, now, click the Submit button below and you will be contacted as soon as Dr. Haley is able to respond about scheduling a meeting with her.

Initial Information Form