Contact form, focus on young adults with OCD

Contact and Pre-screening Form

Thank you for your interest in my specialty practice. Please note, that I am presently prioritizing those seeking treatment for repugnant sexual, harm obsessions and doubting and checking sub-type of OCD with onset within the past 5 years. While I do work with teens 18 and older, I am highly selective when considering a prospective client under the age of 21. I do ask that the person seeking help complete this form themselves. Form filled out by family members will not be considered

Before proceeding, it is important to read through the pages describing my approach as well as the sections describing the condition(s) that match your symptoms. This information will be needed to answer the questions that follow. It can be helpful to have those pages opened in separate tabs. Based on your responses, I will determine whether we would move forward to the next step of setting up a brief telephone screening.

Please note that sensitivity to diversity, inclusion, social justice, reproductive rights, gender equality and non-binary gender identify are woven into my person and, at times, into my work.

Pandemic and COVID-19

Although COVID19 cases and deaths have decreased over the past 6 months, this pandemic, unfortunately, is still with us and consequently, sessions are conducted remotely via video or in-office with, at least, one-way masking. I do require that all prospective clients be vaccinated

First Last Name *

Email Address *

Reason for inquiry * Minimum of 10 characters

Name

Your cell phone number *

Country of Residence

United States

Western/Central Europe

Eastern Europe

Latin America

Other

Employment and Occupation

If you are employed, what is your profession?

If you are a student, what year are you in? What is/are your major(s)?

What is your current living situation? Roommates, Partnered, Children, Living alone? *

Are you presently pregnant

Age

COVID Vaccination Status- Response required

COVID Precautions [Response Required for both columns]

I never mask in public indoor spaces

I sometimes mask in public indoor spaces

I always mask in public indoor spaces

I'm not concerned about re-infection at all

I'm somewhat concerned about re-infection

I believe it is important not to get re-infected

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I am seeking treatment for one or more of the following types of OCD

Other obsessions or compulsions not listed above

If you are seeking treatment for OCD or related disorder I do require that you complete the questions below

If seeking treatment for OCD, please provide a description of your obsessions, related behaviors, the impact of these your life.

When did your symptoms of OCD begin and how have the changed over time [required if you have OCD]

I am seeking treatment for one or more of the following anxiety disorder or conditions

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If you have check off one of the anxiety conditions above a description in the spaces below is required

If seeking treatment for one or more of the anxiety disorder(s) checked above, please provide a description in the space below. Please include the impact on your life, when they began and the progression and/or changes of symptoms over time. If you experience panic disorder please describe the specific symptoms you experience and the fears associated with these

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How do you think the CBT and IBA approaches I use would be helpful to you? Please be specific in your answer. You can open a separate tab in your browser to re-read the Approach page on this site to help you answer this question *

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Impact of pandemic and political/international events

How has the pandemic impacted your life *

If you are living in the US, did the Jan 6th insurrection concern you ? Has Jan 6 had any type of impact you ? If so, in what way(s) *

Have you found the Russian invasion of Ukraine concerning in any way ? If so, in what ways? *

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Please check any of the following conditions, experiences, behaviors or circumstances that apply even if minor

If you have checked any of the conditions above, I do require a description in the space below

Please use this space for any additional comments you might have

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Below is a list of health insurance plans I accept in Massachusetts. Please check if you are covered by one of these or if you will be paying out-of-pocket.

BCBS of New England HMO

BCBS of New England PPO

Tufts Health Plan Commercial

Harvard Pilgrim, United Health, Optum

Allways Health Partners

Other Commercial PPO after deductible is met

None of the above

Please indicate how you will be paying for treatment

I will be using the healthcare plan indicated above

I will be paying out of pocket

What is 5 + 9 - 4 ? *

Contact

Treatment of Obsessional Spectrum Anxiety

6 Harris Street, Newburyport, MA 01950

UN-DOUBT

reasoning solutions

for

obsessions - fears - imaginary shadows

Contact and Pre-screening Form

Pandemic and COVID-19

Treatment of Obsessional Spectrum Anxiety