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Services
Group Offerings
Meet our Team
Client Portal
Request an Appointment

Client Portal
Request an Appointment

Request Appointment

Request Appointment

Request an

Appointment

Let’s get started so we can understand your needs. You will be able to schedule a phone consultation upon submission of this form.

All information is kept strictly confidential. If this is an emergency, please do not fill out this form and instead dial 911 on the nearest phone.

What is your name?*

What is your home address?*

Street Name

City

State

Postal Code

What is your email address?*

What is your phone number?*

How did you hear about us?*PediatricianPsychiatrist/PsychologistSchoolWeb SearchSocial MediaEmail NewsletterOther

What is the patient's name?*

What is the patient's date of birth?*

What is the patient's assigned gender?*MaleFemale

Where does the patient attend school?*

What grade is the patient in?*

What is your primary concern? Select all that apply.*Parenting IssuesAnxietyBehavioral DifficultiesADHDOCDDepression or Mood ConcernsTraumaParenting IssuesOther

Has the patient been in psychotherapy before?*YesNo

Is there any additional information you'd like to provide?

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New York, NY 10019

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Disclaimer:

The information presented on this website and other materials, is solely educational and informational in nature. It is not medical advice, diagnosis nor treatment and does not replace or substitute for obtaining mental health treatment or consultation from an appropriate professional licensed in your state. Whole Mind Psychology, PLLC and Rachel Shelley, Ph.D. accepts no responsibility or liability whatsoever for the use or misuse of the information contained on this website. When you visit or interact with our sites, services or tools, we or our authorised service providers may use cookies for storing information to help provide you with a better, faster and safer experience and for marketing purposes.