This questionnaire assists us by securely gathering information so that our concierge can help you in the most efficient and sensitive way possible during your consultation. Upon submitting this form, you will be redirected to our booking calendar where you may schedule your consultation at your convenience.

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This form should take approximately 10 minutes to complete.

 

You will be need your insurance card IF you are a student under Wellfleet Health Insurance for NYU, Sarah Lawrence College, and School of Visual Arts, or if you are under Aetna Student Health for Columbia University, FIT, and Pratt Institute.

 

Scheduling an initial consultation with Repose and completing the necessary documentation for this consultation does not establish a professional nor therapeutic relationship and is not intended to be a substitute for professional services.

 

We are serious about your privacy. Your Protected Health Information (PHI) is stored in our HIPAA compliant online office system. No personal information is ever shared without your explicit consent and will be only used by Repose for your treatment needs.

 

Experiencing suicidal thoughts is not uncommon when someone is struggling with depression or experiencing acute stress. If you are having thoughts about harming yourself, it is important for us to understand more about what you are experiencing to ensure that we can offer the level of care you require at this time. We ask that you answer the questions we ask about suicidality as honestly and descriptively as possible. Your health and wellness are our top priority and we want you to get the help you need.

 

Please note: Repose does not offer immediate crisis response services, so if you feel you are in imminent danger of harming yourself or someone else, DO NOT WAIT. Call 911, go to your nearest emergency room, or contact a 24/7 crisis resource such as the National Suicide Prevention Lifeline: 1-800-273-TALK (8255).