Name

First Name

Last Name

Email

Phone Number

(###)

###

####

Age

Adult (over 18)

Minor (under 18)

Tell me a little more about what what you would like to explore in therapy:

Daily Availability (check all that apply):

Monday

Tuesday

Wednesday

Thursday

Time Availability (check all that apply):

Morning (8am-11am)

Afternoon (12pm-3pm)

Evening (4pm-7pm)

How did you hear about me?

Let’s work together.

If you are looking for a therapist and are based in NY, I’d love to hear from you!

I will respond in 1 business day of your inquiry.