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New England Center for OCD & Anxiety New York
Please fill out this form, and our clinic manager will get back to you as soon as possible to schedule your free phone consultation to see if we can best support you or your loved one's needs.
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Name (person seeking treatment)
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Your answer
Name of person filling out this form (if different)
Your answer
Date of Birth (of person seeking treatment)
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MM
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YYYY
Email
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Your answer
Phone Number
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Your answer
As your primary insurance, do you receive Medicare, Medicaid, or another federally funded insurance?
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Yes
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Gender
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Male
Female
Non-binary
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Other:
Home Address
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Your answer
Why are you seeking out services?
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Your answer
Which services were you seeking?
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General Outpatient Services (individual, group, family, and couples therapy options)
Intensive Outpatient Program - "IOP" (for clients seeking/will benefit from more frequent sessions)
Group Therapy
Unsure what is best option for person seeking services
Required
How did you hear about New England Center for OCD and Anxiety New York?
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Your answer
Have you been given a diagnosis from a mental health professional?
If yes: what, by whom, and when?
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Your answer
Do you have any specific questions about our programs?
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