If this is an emergency, please dial 911 or go to your nearest emergency room. Email: dr.rachel.hechler@gmail.com Call: (518) 620-7670 Please do not include private or confidential information. First Name Last Name Email Phone Number Date Of Birth Where Are You Located? New JerseyNew YorkFlorida Are You Seeking Services For Yourself Or Someone Else? SelfSomeone Else If You Are Filling Out The Form For Someone Else, Please Include Their Name And Your Relationship To Them Below Preferred Name & Pronouns Briefly Describe What Brings You Here Please do not include private/sensitive information as this form is not HIPAA compliant Availability Preferences Please provide preferred days/times for sessions How Can We Get Back To You? Select all that apply E-MailPhone (you are authorizing us to leave a message) How Did You Hear About Dr. Rachel?