Request an Appointment

Emergency Assistance

Suicide and Crisis Lifeline: Dial 988
Crisis Text Line: Text 741741
Ulster County Mobile Mental Health: 1-844-277-4820 (10 AM-10 PM)
Family of Woodstock 24/7 Crisis Line: Call/Text: 845-679-2485
Dutchess County 24/7 Crisis Line: Call/Text 877-485-9700
Orange County 24/7 Crisis Line: Call 311
Text4Teens: Text 845-391-1000
911

Client Information

First name

Last name

Date of birth

Gender

Client status:

new current returning

Contact Information

Street address

City/Town

Apt. #

State

Zip Code

Phone number (with area code)

Is this a cell phone?

Yes No

Email address

How may I contact you? Check all that apply.

Call

Text

Voicemail

I will download the Spruce app for secure texting.

You are encouraged to use this app if texting me.

(Click here to download Spruce.)

If you check the box allowing me contact you by text, you agree to receive (you "opt in" to receiving) SMS text messages related to services that I am providing to you. Message and data rates may apply, and message frequency varies. You may text me STOP at any time to opt out of receiving SMS text messages from me. You may text us HELP at any time to receive help.

Emergency Contact

First name

Last name

Phone number (including area code)

Relationship

In case of emergency, do I have permission to contact this person?

Yes No

Reasons for Therapy

Indicate services sought:

Individual therapy

Couples therapy

Family therapy

Check all formats of therapy you are open to:

In person

Teletherapy

Why are you seeking therapy at this time?

Describe any significant life changes or stressful events you have recently experienced.

Describe any goals or outcomes you hope to achieve from therapy.

About You

Family

If you are in a relationship, name and age of partner:

Do you have children?

Yes No

If yes, names and ages:

What are your parents names and ages?

Do you have siblings?

Yes No

If yes, names and ages:

Please indicate names and ages of any other significant people important to why you are seeking therapy.

Work/School

What is your occupational or educational status? Check all that apply.

Employed full-time

Employed part-time

Unemployed

In school full-time

In school part-time

If employed, list job and employer:

If in school, list school and field of study:

History

Have you previously been in psychotherapy?

Yes No

Are you currently in psychotherapy?

Yes No

If yes to either of the above, please provide dates, therapist names, and reasons for attending therapy:

Are you currently taking medication?

Yes No

If yes, please list all medications and reasons why each was prescribed:

Are you pregnant?

Yes No Not sure

Do you have any pre-existing medical conditions?

Yes No

If you have any pre-existing medical conditions, please list below:

Are you currently involved in any active court cases or litigation?

Yes No

If yes, briefly explain:

Additional Information

If there is anything else that you would like me to know, please indicate it here:

Your Availability

Please list days and times during the week when you are available. Sessions are typically 45-50 minutes.

Insurance Information

Do you have health insurance?

Yes No

Do you plan to use health insurance to cover therapy?

Yes No

Regardless of whether you plan to use it, please provide the following information if you have health insurance:

Insurance company

Insurance ID number

Group ID number

Your date of birth

Insurer phone number for providers

If patient is not the policy holder, please provide the following:

Policy holder name

Policy holder email

Policy holder date of birth

Policy holder phone number (with area code)

Your information will be encrypted.

Dr. Jonathan D. Raskin

Licensed Psychologist, NY License #013081

Dr. Raskin offers insight-oriented, context-centered, solution-focused, non-pathologizing psychotherapy for adults and adolescents facing problems with relationships, family, career, life transitions, depression, anxiety, sexuality, and bereavement. Dr. Raskin is on many insurance plans as a covered provider. Check with your insurer to confirm.

Telephone and Text: 1-845-582-3107
raskin-psychology.square.site
New Paltz, NY, 12561, USA