Name * First Name Last Name Preferred pronouns Email * Phone * (###) ### #### What insurance do you have? * United Optum Oxford Oscar Cigna Aetna None of these If I do not accept your insurance, what is your budget? Are you located in the state of NY? * Yes No Are you looking for virtual therapy? * Yes No What days/times are you available for weekly sessions? * Message * Thank you! I will review your responses and get back to you shortly! Let’s work together