Name *

First Name

Last Name

Phone *

(###)

###

####

State Where You are Located *

All sessions are conducted remotely however, in order for us to work together, it is required that I am licensed in your state. The states where I am currently licensed to practice are as follows:

New York

New Jersey

Massachusetts

Rhode Island

Payment Options (Payment Due at Time of Session) *

Self-Pay: Standard Rate ($225/Individual; $325/Relationship))

Self-Pay: Sliding scale rate (Range: $160 to $325/session, discussed during intake and re-assessed semi-annually)

Referral to an In-Network Provider or a provider with a self-pay rate lower than $160/per session

I am looking for: *

Ongoing Individual Psychotherapy

Sex Therapy

Relationship Therapy with 2 or more partners

Solution-Focused Coaching

Other (Specify Below):

Weekly Availability *

Please indicate the days/times when you are available on a weekly basis:

Mondays between 1pm and 4pm

Tuesdays between 10am and 4pm

Wednesdays between 1pm and 4pm

Thursdays between 10am and 4pm

I require evening availability on Mondays or Wednesdays between 5pm and 8pm (waitlist)

I am not consistently available during the specified times and would like to request a referral to another provider