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Spano Psychological

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Reason for care

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1 Appointment info

2 Prescreener

Reason for care

3 Contact information

Select the service this inquiry is for:

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Comprehensive Psychotherapy (45 min sessions) Neuropsychological Testing (i.e., Diagnostic clarification, ADHD, Learning Disorder, ASD) Brief Psychotherapy (requires a 60 minute initial evaluation, then 20-30 minute follow ups) One time consultation

What are the primary symptoms or concerns?

Anxiety (Generalized, OCD, etc) Depression Relationship and family issues Adjustment to new stressor(s) Grief and Loss General Life Stressors Emotional Regulation Women's health concern (i.e., pregnancy, postpartum, menopause) Mood Disorder Behavioral issue Concerns related to Autism Spectrum Disorder ADHD symptoms Other (Please provide more information at the end of this form)

What previous mental health services has the patient engaged in?

Select all that apply

Individual psychotherapy Medication management Inpatient treatment program Psychoeducational or Neuropsychological Testing (past) Partial Hospitalization Program (PHP) and/or Intensive outpatient program (IOP) This is my first time pursuing psychotherapy

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

Spano Psychological

267.225.4122 |

Philadelphia

Main Location

Philadelphia, PA 19102-3604

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.