New Patient Inquiries

Welcome
About Dr. Solomon
Process for New Patients
Practice Information
SERVICES
Contact Dr. Solomon
FAQs About Treatment
Fees & Insurance
RESOURCES
E-Courses

Services for Minors
Inquiry and New Patient SCreening Form

Insurance: Dr. Solomon does not accept insurance, she is not in-network, but she is considered an Out of Network (OON) provider. Therefore, every patient/family is provided all invoicing and superbills necessary to submit for claims. You can check with your insurance company to see what your OON benefits are and what your deductible is to start receiving reimbursement for OON services. Please check the box to confirm, YES, you understand this. *

YES, I understand that Dr. Solomon does not accept insurance and services are private pay only.

* Indicates required field

Name of the person completing this form *

Phone Number *

Email *

City and State of Residence *

Name of person you are seeking services for *

Age of the person you are seeking services for *

How did you find out about Dr. Solomon? (Check all that apply) *

Internet Search Referral by Healthcare Provider Professional Organization Directory Search Friend of Family Member Current or Former Patient Social Media (Facebook, Instagram, etc.) School Staff Other

Dr. Solomon specializes in the treatment of the concerns below. What are the primary concerns of the minor (check all that apply): *

OCD Generalized Anxiety/Worry Social Anxiety Emetophobia Other Fears/Phobias Health Anxiety Separation Anxiety Panic Attacks School Anxiety/School Refusal Hair Pulling/Skin Picking (BFRBS) Tics/Tourette Syndrome Other (please describe in the comments section)

Please let us know if any of the following events or actions have occurred as it relates to the prospective patient (check all that apply) *

Acting out with physical aggression Suicidal thoughts Suicidal attempts or behaviors Self Harm/Self Injury (e.g. cutting, hitting self) Substance or Alcohol Use Hospitalization for psychiatric reasons Binge eating, purging, or restrictive eating Running away from home Criminal acts other than substance or alcohol use

Comment *

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DR. ALLISON SOLOMON, PSY.D., PC
Licensed Clinical Psychologist
Phone: 631.403.0863
Fax: 480.269.9104
EMAIL: [email protected]

Welcome
About Dr. Solomon
Process for New Patients
Practice Information
SERVICES
Contact Dr. Solomon
FAQs About Treatment
Fees & Insurance
RESOURCES
E-Courses

Services for MinorsInquiry and New Patient SCreening Form

DR. ALLISON SOLOMON, PSY.D., PCLicensed Clinical PsychologistPhone: 631.403.0863​Fax: 480.269.9104EMAIL: [email protected]

Services for Minors
Inquiry and New Patient SCreening Form

DR. ALLISON SOLOMON, PSY.D., PC
Licensed Clinical Psychologist
Phone: 631.403.0863
Fax: 480.269.9104
EMAIL: [email protected]