Child Therapy & Play Therapy in New Rochelle, NY

Guardian Information

Child Information

Guardian Information

First Name:

Last Name:

Phone:

Email:

Relation:

Child Information

Child First Name:

Child Last Name:

Date of Birth:

Preferred contact method: EmailPhoneEither is fine

Medium Virtual OnlyIn PersonVirtual or In Person

Seeking therapy because: They’re showing signs of anxiety or fearfulnessThey’ve been unusually sad, withdrawn, or irritableThey’re having behavioral outbursts or trouble following rulesThey’ve experienced a stressful or traumatic eventThey’re struggling with attention or hyperactivityThey’re having trouble making or keeping friendsThey’re experiencing changes at home (divorce, loss, move)They’re not sleeping well or having nightmaresThey’re showing signs of low self-esteem or confidenceSomething 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.