Helpful Forms

If you're a new client, please complete the following forms and bring them to your first therapy session.

  • Client Psychotherapy Intake Form
  • Limits of Confidentiality/Therapy Cancellation Policy

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

  • Authorization to Disclose Information Form
Client Psychotherapy Intake Form
Limits of Confidentiality/Therapy Cancellation Policy
Authorization to Disclose Information Form

Note: To download Adobe Acrobat Reader for free, click here;.

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Helpful Forms

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Staten Island, NY Therapist

Michael De Simone, Ph.D,LCSW


Staten Island

175 Burbank Avenue
Staten Island, NY 10306
1-917-301-5962
 

Manhattan

26 West 9th Street, 4D
New York, NY 10011
1-917-301-5962

[email protected]