Robin D. Stone, LMHC
Psychotherapist, Author, Speaker
Work With Me
About
Meet Robin
Meet My Team
Workshops + Speaking
Past Workshops + Speaking Engagements
Upcoming Events
Journalism
My Background
Portfolio
No Secrets, No Lies
THICK Film
Blog
Contact
Robin D. Stone, LMHC
Psychotherapist, Author, Speaker
Work With Me
About
Meet Robin
Meet My Team
Workshops + Speaking
Past Workshops + Speaking Engagements
Upcoming Events
Journalism
My Background
Portfolio
No Secrets, No Lies
THICK Film
Blog
Contact
Potential Client Contact Form
Please complete the form below as you speak to a potential client. The completed form will be sent to Robin.
Clinician Name
*
Clinician completing form
Potential Client Name
*
First Name
Last Name
Preferred Name
*
Email
*
Most Accessible Phone Number
*
(###)
###
####
State where you live? (must be New York)
*
Gender
*
Female
Male
Other
Preferred Pronouns
*
How can we help you?
*
What do you hope to be able to do or achieve as a result of working with a therapist?
*
How do you handle stressors and/or cope with the problems you have described?
*
What times would you be available for sessions?
*
Days of the week & times Mornings: 9am - 12noon Afternoons: 1 - 4pm Evenings: 5 - 8pm
Would you be paying out of pocket or seeking out-of-network insurance reimbursement? (Practice is not in network for health insurance)
*
Out-of-pocket
Out-of-network reimbursement
I will share your information with Robin. If she is not available, are you open to working with another clinician on Robin's staff?
*
Yes
No
(If yes) May we have that clinician contact you?
Yes
No
How did you hear about Robin?
*
Friend/Family
Another mental health facility/program
Article
Therapy for Black Girls
Psychology Today
Clinicians of Color
Google
Other
Other
Thank you!
