Cohesive Therapy NYC | Consultation Request Form

The Basics

Are you located in New York State?*

Yes, I will be located in New York State and will be able to confirm that if we were to move forward with treatmentNo, I am not located in New York State

What is your first name?*

What is your last name?*

What is your email address? *

What is your mobile phone number?*

New York State licensure law requires that clients or patients are physically located in the state of New York during the time of treatment. Kindly note that should we move forward, we are required to verify your location.

What are you seeking help with?

Which of the following best describes why you are reaching out? *

Please provide any additional information that you feel would be helpful in further understanding your needs:*

Rates and Insurance Questions

Cohesive Therapy NYC is out-of-network with all insurances, but your plan may provide out of network benefits that provide you with partial reimbursement. See our FAQ page for more information

Medicaid/Medicare recipients: If you are a Medicare or Medicaid recipient, kindly note that Medicare and Medicaid regulations do not allow for out-of-network claims submission for reimbursement. Therefore, you should expect to pay for sessions fully out-of-pocket.

Sliding Scale/Discounted Rates: Due to the limited number of spots available, sliding scale/discounted rates are not available.

I’m interested in:*

Your Availability

Please provide at least two days and times between 9:30am- 4:00pm that may work for you to meet:*

How did you find us?*

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