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TELL US ABOUT THE NYP EMPLOYEE

Campus Location

NYP Employee Role

NYP Work Email Address

TELL US ABOUT YOURSELF

Are you an employee or household member?

If you are a household member, what is your relation to the employee?

First Name

Last Name

Full Name of Employee if you are household member

Phone Type

Cell Phone Number

Secondary Phone Number

Invalid value

Preferred Email Address to contact you

Date of Birth

Home Address

City/Town

State

ZIP/Postal Code

Emergency Contact Name, Phone Number & Relation

Reasons for Support

What brings you to CopeNYP?

How did you hear about CopeNYP?

Is this your first time receiving mental health support?

Preferred modality of Counseling Sessions

What is your primary insurance?

Insurance Plan Type (ex; EPO, PPO)

Insurance Other:

Do you work from home?

What shift do you predominately work?

Preferred Counseling Days
Which days/times do you prefer to have the counseling sessions? Please note that we cannot guarantee specific times.

Monday

Morning

Afternoon

Early Evening

Not Available

Thursday

Morning

Afternoon

Early Evening

Not Available

Tuesday

Morning

Afternoon

Early Evening

Not Available

Friday

Morning

Afternoon

Early Evening

Not Available

Wednesday

Morning

Afternoon

Early Evening

Not Available

Demographic Information

Gender Identity

Race/Ethnicity

Pronouns

Pronouns Other:

Sexual Orientation

Sexual Orientation Other:

Highest Education Level

Relationship Status

Household composition

Number of children *If none, please input 0

Ages and Gender of Children

Employment Status

Immediate family psychiatric history

None

Alcohol Use Disorder

Anxiety

Depression

Bipolar

Child abuse

Drug misuse/abuse

Domestic abuse

Schizophrenia

Other

PHQ-9 (Over the last 2 weeks, how often have you been bothered by any of the following problems?) Please read these questions carefully and answer them thoughtfully. Your answers help determine how we can best support you.

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading or watching television

Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead, or of hurting yourself

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? (PHQ-9)

GAD-7 (Over the last 2 weeks, how often have you been bothered by any of the following problems?)

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it is hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? (GAD-7)

WOS Assessment (Please ONLY complete this if you are an NYP employee. If you are a household member please click N/A below.) Below is a series of statements that refer to aspects of your work and life experience during the past 30 days that may have been affected by personal problems. Please read each item carefully and answer as accurately as you can. If you work from home or other worksites or conduct your work during evening or overnight shifts, please answer for your context.

So far, my life seems to be going very well

I am often eager to get to work and start the day

I dread going into work

My personal problems kept me from concentrating on my work

How many hours of work did you miss in the past month?

PCL

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:

a serious accident or fire
a physical or sexual assault or abuse
an earthquake or flood
a war
seeing someone be killed or seriously injured
having a loved one die through homicide or suicide.

Have you ever experienced this kind of event?

In the past month, have you

Had nightmares about the event(s) or thought about the event(s) when you did not want to?

Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?

Been constantly on guard, watchful, or easily startled?

Felt numb or detached from people, activities, or your surroundings?

Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

Submit

STATEMENT OF UNDERSTANDING

CopeNYP Exceptions: Coverage is not available for family members who do not live in the household, with the exception of adult children up to age 26 who are on the parent’s health insurance and who attend college or live in NY, NJ, CT or PA.Coverage is not available for clients who are already actively engaged in psychotherapy or counseling unless they are actively looking for a new mental health counselor. Employees residing in states other than NY, NJ, CT and PA may only be eligible for initial consultations and referrals to local clinicians through their health insurance, or other community resources, due to licensure restrictions.

CopeNYP Cases Involving Children: Cases involving children(1-12 years old) and minor adolescents(13-17 years old) are handled in the following manner:

Adolescent(13-17 years old) : CopeNYP Individual Counseling will be provided to minor teens(ages 13-17) when the clinician determines that it is a clinically appropriate intervention, and when the custodial parent agrees to this treatment.The parent MUST be present at the start of the first session, where confidentiality and its limits will be reviewed with the parent and adolescent.The parent may then be dismissed from the session (if the clinician deems it appropriate) but must remain present and available throughout the session’s entire duration, as the clinician may wish to circle back to the parent to discuss risk or treatment planning issues, or family dynamics.

Children(1-12 years old) : Intakes for children are conducted from the parents’ point of view on the situation. Families with presenting problems where the identified patient is 12 years old or younger will be informed that CopeNYP will provide them with parent counseling/coaching, and, depending on the clinician’s expertise and clinical judgment, possibly have parent-child joint sessions, but we will not be doing individual child therapy with children in those age ranges. If the clinician deems individual child therapy (or play therapy) to be the best clinical recommendation, CopeNYP will do its best to locate an appropriate external referral for your child/family.

Consent Full Name*

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CopeNYP Counseling Services

Online Request Form for Counseling Services

If you are experiencing a life-threatening emergency/situation or are having thoughts to harm yourself or others, do NOT fill out this form. Instead, immediately call 911 or go to the nearest emergency room.