Name *

First Name

Last Name

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)

Location:

We have limited NY office availability, but all therapists offer virtual sessions. Please specify which location suits you the best.

NY/MA/OR: Telehealth ONLY

NY: I would like to meet in-person (at least most of the time)

Payment Options:

Full Self-Pay ($160-$400)

Reduced Self-Pay, no insurance ($120-160)

I am an Aetna member

I'd like to use my Out of Network benefits and I am aware that my deductible may renew in January

I would like to see an intern at a fee of $50-$75 beginning September 2023

I'm not sure what my benefits are

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

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

I would like to opt-in to receive periodic newsletter emails about upcoming groups, general announcements, and other non-spamming information.

Yes, sign me up!

Not at this time