Are you physically located in New Yok State? *

Please kindly note that we are only licensed to see individuals who are physically located in the state of New York at the time of the session.

Yes, I am/will be physically in New York at the time of the session.

No, I am not located in New York.

Legal Name *

First Name

Last Name

Preferred Name

First Name

Last Name

Birthday *

MM

DD

YYYY

Phone *

(###)

###

####

You are looking for: *

Individual Therapy

Couple/ Relationship Therapy

Both Individual and Couple Therapy

Psychotherapy for my minor child

Other

Daily Availability (check all that apply) *

Monday

Tuesday

Wednesday

Thursday

Friday

Time Availability (check all that apply)

Morning (8am-10am)

Late Morning (10am-12pm)

Mid-Day (12pm-2pm)

Afternoon (2pm-4pm)

Late Afternoon (4pm-6pm)

Evening (6pm - 8pm)

Acknowledgement *

By submitting this form, you acknowledge and accept these terms.

I understand and agree that any information submitted will be forwarded to the Practice via email and not via a secure messaging system. This form should not be used to transmit private health information, and the Practice disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form. I understand and agree that submitting this form does not establish a therapist-client relationship.