New Patient Form

Please complete and submit the following form. This information is required before we can begin work. This form is completely secure, but if it makes you feel more comfortable, you may wish to complete the form, print it out and fax it to Dr. Conti at 860.659.4358.

Your Name (required)

Your Email (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Phone (required)

Date of Birth (required)

Emergency Contact Name (required)

Emergency Contact Phone (required)

Method of Counseling (required)

Availability for the next 7 days (required)

May we call you? (Please note: a message will be left) (required)

Briefly describe the problem or situation that led you to contact us. Please indicate how you found us or who referred you to us. (required)

Are you having any current suicidal and/or homicidal thoughts or intentions? (required)

If the answer to this question is YES, then call 1.800.SUICIDE or your nearest crisis/suicide hotline. If you are in immediate danger, call 911 NOW.

List any current medications you are taking.

If so, for what condition(s)?

Will you be using insurance to cover your mental health counseling/treatment? (required)

If yes, please indicate the name of your insurance company for mental health counseling/treatment. Insurance Information

Are you using an Employee Assistance Program benefit (EAP)? (required)

If yes, what is the name of your EAP?

I understand and accept the terms and conditions for working with Dr. Conti at HELPsychology.com

Types Of Counseling