Prospective Client Pre-Screening Form

Board Certified Clinical Psychologist Licensed in NY, NJ, CT, MA, VA, HI Offering in-person and virtual individual psychotherapy Monday-Friday

Name:

Telephone number:

Email address

Please briefly describe what you'd like to accomplish in therapy?

I am an out of network provider, meaning I do not accept any health insurance. I do provide a superbill if you are using out of network benefits.

Please check if you have out of network benefits

Please check if you are not using out of network benefits

What days and times are you generally available on a weekly basis?

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