Contact This form is not HIPAA-compliant. Keep this in mind when submitting personal health information (PHI). * Ok, got it. Name * First Name Last Name Phone * (###) ### #### Email * We only offer services to people located in New York and all sessions are virtual. * I am located in New York Please ONLY submit this form if you are genuinely interested in getting started and want to see if we are a great fit/really want to learn more. ***I set aside time to respond to you and save a spot for your genuine interest in getting started! * Got it! Yes, I am motivated and genuinely interested in getting started. What is your motivation, 1 out of 5 (5 being highly motivated) to get started, get relief, and make progress? * 1 (Not Motivated) 2 3 4 5 (Highly Motivated) How did you hear about us? * Google Facebook Instagram Word of Mouth Other We are an out-of-pocket practice [and we take UnitedHealthcare, Oxford Health Plans, Cigna, Aetna, and Empire Blue Cross Blue Shield insurances. * Confirm by typing "I understand": What are you struggling with the most and hoping to get relief around? * What have you tried before to get relief, and has it worked? * Would you like us to reach out to you by texting you or by emailing you? * Text me! Email me (make sure to check your junk mail as well, within the next 24 business hours) Text and email me, please! If you selected to be “texted” above, please type the phone number you want us to text you at OR put “N/A”: * Thank you for filling out this form, we will get back to you in less than 24 business hours! Please make sure to check your junk mail. * Ok, got it! Thank you!
