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 treatment of OCD, doubting and checking sub-types, unwanted sexual, harm obsessions and Contamination-Washing as well treatment for travel/transport agoraphobia related to panic and Fear of Flying related to both fear of accidents and/or Panic

Before proceeding, please read through my Approach page as well as the sections describing the condition(s) that you are seeking treatment for. Your responses, will help me decide whether we would move on to setting up a brief telephone screening.

Please note that sensitivity to diversity, inclusion, social justice, reproductive rights, gender equality, LGBTQ+ rights and gender fluidity are respected and protected in this practice.

First Last Name *

Email Address *

Reason for inquiry * Minimum of 10 characters

Name

Your cell phone number *

Please indicate your country of residence and whether you live in Massachusetts

United States

Massachusetts

Western/Central Europe

Eastern Europe

Latin America

Other

Employment and Occupation- field is required

If you are employed, what is your profession? *

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

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

Are you presently pregnant

Age- answer is required

COVID Vaccination Status- Response required

————————————————————————————————————————————————————————————————————————————————

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

If seeking treatment for OCD, please provide a description of your obsessions and compulsions and impact of these your life. If not relevant, write N/A *

When did your symptoms of OCD begin and how have the changed over time [If you don't have OCD, write N/A *

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

————————————————————————————————————————————————————————————————————————————————

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 .. Otherwise write N/A

*

————————————————————————————————————————————————————————————————————————————————

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 *

————————————————————————————————————————————————————————————————————————————————

Impact of pandemic and political/international events

How did the pandemic impacted your life *

Have you found any world or national events concerning. Have they contributed to your anxiety? *

————————————————————————————————————————————————————————————————————————————————

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 or type N/A *

Please use this space for any additional comments you might have

————————————————————————————————————————————————————————————————————————————————

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

Other Commercial PPO after deductible is met

None of the above

Please indicate how you will be paying for treatment- Required field

I will be using the healthcare plan indicated above

I will be paying out of pocket

I am experiencing some technical difficulties. If form submission fails, please email me with summary of responses to contact@robertsafion.com

What is 5 + 9 - 4 ? *

Contact

Treatment of Obsessional Spectrum Anxiety

10 Prince Place, Newburyport, MA 01950
USA

Virtual offices in the UK, Germany, Netherlands and other Western and Eastern European countries

UN-DOUBT

reasoning solutions

for

obsessions - fears - imaginary shadows

Contact and Pre-Screening Form

Treatment of Obsessional Spectrum Anxiety