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Referring Provider Details

No Waitlist – Clients are scheduled based on their own availability.

Referring Provider Name

Practice/Clinic Name
Practice/Clinic Phone Number

Email Address
Fax Number

Reason for Referral
Individual TherapyFamily TherapyCouples TherapyChild TherapyAdolescent TherapyGroup TherapyEMDR TherapyAnger ManagementCourt-Mandated CounselingTrauma-Focused CounselingMood Disorders e.g.- depression, bipolarAnxiety - Stress-Related DisordersWomen’s issueMen’s issueOther

Client Information

Client First Name
Client Last Name

Enter your Date of Birth

Phone Number (or guardian contact)
Email Address

Insurance (if known)

Session Preferences

Session Type
In-person or virtualVirtual Only

Preferred Day(s)
MondayTuesdayWednesdayThursdayFridaySaturdayI don't have a preferencePreferred Time(s)
MorningAfternoonEveningI don't have a preference

Additional Notes
Please attach other necessary documents if available

First Name:

Last Name:

DOB:

Phone:

Email:

What is your preferred contact method EmailPhoneEither is fine

Medium Virtual OnlyIn PersonVirtual or In Person

We’re currently seeking therapy because… We’re struggling to communicate effectivelyWe’ve been arguing more often or avoiding each otherThere’s been a loss of trust or a breach of boundariesWe’re feeling emotionally disconnected or distantWe’re navigating major life changes (kids, work, relocation, etc.)We want to improve intimacy and connectionWe need help deciding whether to stay togetherWe’re co-parenting and facing challengesWe want to strengthen our relationship before marriageSomething else

Thank you for choosing Alssaro Counseling Services!

Before we can book your appointment, you’ll be redirected to Therapy Appointment, our secure HIPPA-compliant platform, to complete your required intake forms.

If you’d rather speak with someone before booking, click below and a member of our team will reach out to assist you.

I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form. By submitting this form, you consent to receive SMS messages from Alssaro Counseling Services. Please note that your number will not be shared with third parties or affiliates for marketing purposes under any circumstances.

Individual Therapy

Individual therapy is a process through which clients work one-on-one with a trained therapist, in a safe, caring, and confidential environment…

Couples counseling session at Alssaro Counseling Services in New Rochelle

Teen Therapy

The teen years are some of the most difficult for both the adolescent and their parents/guardians. They are a time of transition where an…

Couples Counseling

Couples meet in a private therapeutic setting to discuss their relationship issues with trained clinicians. Couples or marriage counseling provides support….

Child Counseling

Unlike adults, when children are distressed they express what is happening through the symbolic language of play rather than verbal language alone…

Child therapy using play-based techniques at Alssaro Counseling Services

Anger Management Classes

Our certified specialists are recognized by the National Anger Management Association (NAMA). The classes are offered individually and in group format…

Anger management class at Alssaro Counseling Services in New Rochelle NY

Online Therapy Counseling

Connect with your therapist via video, phone, iPad, or laptop—whichever works best for you. Enjoy flexible, convenient therapy that fits your lifestyle.

Online therapy and teletherapy session via video call with Alssaro Counseling

Family Counseling

Family counseling is designed to identify family dynamics, interactions, and patterns that prevent the collective growth and harmony of the family…

Supportive Care

Personalized Psychological Support