Appointments

To schedule an appointment, first select either New York or Connecticut under “select location” below. Then click on an available time. If you don’t have an account, you’ll need to create one. Don’t worry, it’s free and easy. You’ll receive a confirmation e-mail, however due to a glitch in the system, please ignore the location stated in the e-mail. After scheduling your appointment, please fill out the bottom portion and send. All information you provide is completely confidential.


Client Name

Address

Cell Phone Number


Home or Work Number


E-mail

Date of Birth

Insurance Co.

Policy #

Phone # on back of card

Name of Policy Holder

Date of Birth of Policy Holder

Number of Visits Authorized

Co-Pay

Previous therapy?

Currently taking any medications, if so then what?

How were you referred to this practice?

What is your most pressing issue?