Name *

First Name

Last Name

Phone number *

(###)

###

####

Age *

My age is between

18-23

24-35

36-45

46-55

56-65

66+

I'm reaching out about: *

Individual Therapy

Relationship Therapy

DBT Group

Other

I am a resident of North Carolina. *

Yes

No

Moving there soon

I am a resident of New York state. *

Yes

No

Moving there soon

I am interested in:

Select option

Telehealth

In person Central NY

My insurance plan is through:

Aetna

Cigna

United or Optum

Excellus BCBS

Other BCBS

MVP

Other

By submitting this form via this web portal, I acknowledge and accept the risks of communicating health information via this unencrypted email and electronic message and wish to continue despite those risks. *

Yes, I want to submit this form and agree to the terms of use.