EMAIL CBT SPECTRUM

To make an appointment or to contact the office with questions

PLEASE NOTE: We are currently only offering video and phone telehealth appointments using video platforms that ensure your privacy. When clinically warranted, Dr. Sachs will see some patients in person, but will charge for travel.

Your Name

First Name

Last Name

Patient's name (if different from above)

Patient's Date of Birth

Email Address

Phone Number

(###)

###

####

Will you require a reduced fee rate to see one of our doctors? (Please note the waitlist for this is approximately 1 year and you will be asked to submit specific financial and insurance reimbursement information for us to make a determination of eligibility)

Do you have Medicare

If a good fit, are you interested in working with a lower-fee trainee therapist?

What is the primary reason why you want to see a doctor?

Are you/your child currently demonstrating school avoidance and/or refusal behaviors?

If yes, please explain

Are you currently working with a therapist or psychiatrist?

Will anyone potentially be joining your session? If yes, who?

What is the general availability (for the Patient and for Parent/Guardian if applicable) Monday-Saturday? (specify ALL available days/times)

What state are you located in? If you are located outside of the United States, please indicate what country you are located in.

Are you interested in in person, virtual, or hybrid therapy?

EMAIL CBT SPECTRUM

To make an appointment or to contact the office with questions

We will do our best to return your email within the week