Reach Out Name * First Name Last Name Pronouns * Identities Identities that would be helpful for me to know about are... Email * Phone * (###) ### #### How did you hear about me? * Briefly, why are you seeking therapy? * How will you be paying for sessions? * I can pay your out of pocket fee of $200 per session I plan on using insurance through Aetna I plan on using insurance through Cigna I plan on using out of network benefits and will need a superbill for reimbursement Other What is your availability for a phone consultation? * What is your availability for sessions? * Are you comfortable with Telehealth sessions via Zoom? * Yes No Maybe - I have questions! Thank you! I am looking forward to connecting with you soon. 24/7 Hotlines National Suicide Prevention Lifeline 800.273.TALK NYC WELL888.NYC.WELLTrans Lifeline877.565.8860
