Name *

First Name

Last Name

Would you like to be on the waitlist for $50 sessions this fall?

Yes

No, I'd like to see how I can meet with someone right away

Client location *

I am physically located in:

New York

Oregon

Massachusetts

Phone *

(###)

###

####

I am looking for:

Individual psychotherapy

Couples/relationship therapy

Both individual and couples therapy (please have each partner submit a separate form)

Psychotherapy for my minor child

Other (will elaborate below)

Payment Preferences: *

I can pay $175-$400

I can pay $130-$175

I can pay $100-130

I can pay $50-$100

I'd like to see how my Out of Network benefits can help with cost

New York: I am an Aetna or Northwell Direct member

Oregon: I am a BCBS or Aetna member

Massachusetts: I am a BCBS or Aetna member

Time of day preference:

Please help us figure out how to best match you

I can only meet after 5pm

I would prefer evenings but can make other times work

I only have daytime availability

Please acknowledge that emails and text messages should not contain sensitive information such as credit card numbers or social security numbers.

I understand that emails and text messages are inherently insecure, could possibly be read by third parties, and should not contain sensitive information.