Patient Questionnaire

Nassau Psychology

Summary

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Patient Questionnaire

Client Full Name *

Date of Birth *

Best call back number *

Email Address *

I am seeking services for *

Do you reside in New York state? *

Yes

Please choose desired location *

Lynbrook(In-Person)

Rockville Centre(In-Person)

Wantagh(In-Person)

Telehealth(Remotely)

Please choose desired time frame *

8:00AM-12:00PM

12:00PM-5:00PM

5:00PM-9:00PM

In the past 6 months, have you left or been discharged from any psychiatric, inpatient, rehab, or detox program? *

Yes

Do you have any active suicidal thoughts? *

Yes

If yes, do you have intent to harm yourself? *

Yes

N/A

If you are experiencing suicidal thoughts, have you taken any actions to harm yourself or attempted to act on these thoughts? *

Yes

Do you currently experience, or have you ever experienced, hallucinations (seeing, hearing, or sensing things that others do not)? *

Yes

Have you ever been diagnosed with Schizophrenia or any other Psychotic diagnoses? *

Yes

Is CPS/APS or court involved in any type of way? *

Yes

Do you have any current or pending court orders related to custody agreements or legal guardianship? *

Yes

Has any court, attorney, or other professional entity required or suggested you attend therapy at this time? *

Yes

Nassau Psychology provides psychotherapy services only. Since we are not a forensic practice, we cannot offer expert opinions, evaluations, or recommendations for legal matters or court‑related purposes. Our role is to support your therapeutic needs, not to provide assessments or documentation for legal proceedings. *

Yes, I agree

Are you seeking any forms or evaluations (i.e. employment, disability, school, emotional support animals, housing, DSS, etc) to be completed? *

Yes

Is there a diagnosis of autism spectrum disorder (ASD)? *

Yes

Is there any current or past serious use or misuse of drugs or alcohol?

Our practice does not specialize in substance use treatment services and may not be an appropriate fit if there is significant drug or alcohol use.

Yes

Patient Questionnaire

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