Initial Consult Request - The (K)Now Clinic
Thank you for your interest in services with Dr. Gustman's private practice, The (K)Now Clinic. The (K)Now Clinic is currently accepting new clients for the following services:
  • Comprehensive Psychoeducational Evaluations (Independent Educational Evaluations) for educational disability identification, service and accommodation recommendations, including testing accommodations 
  • Routine Mental Health Screening Evaluations for screening of your child or teen for common behavioral and mental health symptoms and conditions, with a brief report and recommendations.
  • Educational Consultation & Advocacy Services for families of students Pre-Kindergarten through High School/Transition-Age for special education, educational accommodation, and learning support services (public, private, and parochial schools)
  • Adult Individual Therapy Services for relationship, work-life balance, life transitions 
  • Therapy for Teens and Adults with Neuro-developmental Disabilities
Please complete this form to provide some background information that will help Dr. Gustman use your initial consultation time most effectively. Information collected during this initial referral call DOES NOT establish a provider-client relationship. It is designed to collect information to determine the appropriateness of the referral for the services I offer, and for scheduling. All services are provided on a private-pay or fee-for-service basis as of December 2024.

If you, or someone you know, are experiencing a mental health crisis, then please call 9-8-8 (National Crisis Helpline) or 9-1-1 to get emergency care to help you/them through the crisis.

Responses on this form are generally viewed within 72 hours of submission. If the types of services you are requesting are currently available, you will be emailed three upcoming consultation appointment times for you to choose one that works for you.  

YOUR RESPONSES ON THIS FORM ARE CONFIDENTIAL & VIEWABLE ONLY BY LICENSED AND PRE-LICENSED MENTAL HEALTH PROFESSIONALS AT THE (K)NOW CLINIC, EXCEPT AS REQUIRED BY LAW FOR THE IMMEDIATE SAFETY AND WELFARE OF YOU OR OTHER IDENTIFIED PEOPLE
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Email *
What is your First and Last Name? *
Which of the following times could work for our 15-20 minute initial consultation call (via Zoom)? *
Required
Date of Birth *
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What is your Preferred Phone Number? *
Preferred Email Address *
Mark below if we may leave confidential information for you via these means:  *
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For whom (Primary Client) are you seeking psychological services? (Please note, services may only be scheduled for yourself or people for whom you are their legal guardian.) *
If the Primary Client is someone other than you, then provide their First and Last Name (or organization/agency name) here:
What is the name the Primary Client goes by?
What are Primary Client's pronouns?
What psychological service(s) are you seeking? *
Required
Provide a brief summary of the reasons you are seeking psychological services (e.g., testing accommodations, school learning support plan, special education eligibility, feeling depressed/anxious, past or current traumatic experiences, panic attacks, hopelessness).
Are the services you are seeking related to a current or anticipated civil, divorce, custody, or other legal purpose (saying "Yes" will not disqualify you from services)?  *
You are aware that the services you are seeking are provided to you as a private-pay service, which may or may not be reimbursable, and that fees are due at the time of service. *
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