Ready to Talk?

Name *

First Name

Last Name

Phone Number *

(###)

###

####

Preferred Contact Method *

Email

Phone

Can I leave a voice message on your phone? *

Yes

No

Text me instead

Who are you seeking therapy for?

Myself

My Child/Teen

Someone else

Preferred Session Times *

(Select all that apply)

Mornings

Afternoons

Evenings

I'm Flexible

Preferred Session Format

In-person in Oceanside NY

Virtually via Zoom

Hybrid of in-person and Zoom

Not Sure Yet

My practice is private pay only. Are you comfortable proceeding without using insurance? *

Please note: I am an out-of-network provider and do not accept insurance. Many of my clients get some form of insurance reimbursement and I’m happy to provide a superbill for this possibility through your insurance plan.

Yes

I'm Not Sure Yet

I’d like to talk more about this in the consult