Request for free phone consultation (pediatric version)
Please complete the following questionnaire in order to receive a free phone consultation. We will call you back within one business day to discuss your concerns and to see whether you'd like to set up an appointment for an initial evaluation/consultation.
This questionnaire is for potential new patients only. Current patients should not submit health information through this website. Please contact us via phone or email if you would like to discuss any health matters further.
PLEASE NOTE: By pressing Submit, you are agreeing to transmit health information electronically. This is an informal request for information from non-patients. All paper and electronic information for current patients is stored by our office in a manner compliant with HIPAA, however we cannot guarantee the security of information transmitted by third-party servers for current non-patients.
If you are a current patient, please DO NOT use this form to transmit information. Please call 347-676-0332 to arrange a phone call with your therapist.