Dr. Irina Gorelik Psychological Services PLLC

Who would be receiving care?

Someone else

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First name

Last name

Phone

State

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Age of Client

Reason for care

What is the reason for seeking care?

(You can add brief details here for some context, but this will be discussed in more detail in the call and intake session, if you choose to proceed)

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Administrative

Referral source

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Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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What are some times of day that work for a 10-15 min consult call? Please provide a few general time ranges.

Billing & Payment

Please note: I am not in network with any insurance plans at this time and offer services on a private-pay basis. I’m happy to provide a superbill for potential out-of-network reimbursement, and I can send you helpful questions to ask your insurance provider to check your benefits.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.