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Soho Integrative Psychological Services, PLLC

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Reason for care

Select date & time

1 Appointment info

2 Prescreener

Reason for care

3 Contact information

What is the reason for seeking care?

Eating issues Habits Addiction Sleep Confidence issues Attentional difficulties Anxiety-related issues (e.g, general anxiety, social anxiety, phobias, OCD, etc.) Depression or Grief Pregnancy or Parenting Trauma Sexual issues Health issues (e.g., IBS, brain injuries, chronic pain, other) Relationship Issues Other

If other reason for seeking care please specify below:

What mental health concerns or treatment have occurred in the past?

In therapy now Taking medication for any mental health concern Hospitalized for mental health reasons in the past 2 years In the past 2 weeks, had thoughts of harming yourself In the past 2 weeks, had thoughts of ending your life Attempted suicide in the past None of these apply

Do you have any current or past concerns about your use of alcohol, drugs, or other substances?

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Do you experience challenges with eating patterns, body image, or behaviors such as restricting, bingeing, or purging?

Yes No

Is there anything else you would like us to know?

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

Soho Integrative Psychological Services, PLLC

646.537.1713

New York

Main Location

New York, NY 10012

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.