Cohesive Therapy NYC | Consultation Request Form

The Basics:

What is your first name? *

What is your last name? *

Please confirm that you are 21 years or older. *

Yes, I am 21 years or older

What is your email address? *

What is your mobile phone number? *

Protect your privacy: *

I understand that emails and text messages are inherently insecure, could possibly be read by third parties, and should not contain sensitive information.

New York State Telehealth Laws Acknowledgement: *

I understand that if we were to move forward with treatment, New York State law requires that I am physically located within New York State at the time of our telehealth sessions.

What are you seeking help with?

Which of the following best describes why you are seeking therapy? *

Have you had any suicidal plans or attempts within the last 6 months? *

Kindly note that we are unable to any provide crisis or after-hours response. If you have had any suicidal plans or attempts within the last 6 months, or are still experiencing active suicidal thoughts or attempts, we encourage that you seek help from readily available resources.

NEED HELP?

National Suicide Prevention Lifeline: 1-800-273-8255

Crisis Text Line: Text HOME to 741741

Veterans Crisis Line: 1-800-273-8255

LGBTQ Resources:

Trans Lifeline: 1-877-565-8860

The Trevor Project: 1-866-488-7386

Please call 911 if you are in case of an emergency or if in need of immediate assistance.

What, if any, mental health diagnosis have you received in the past? *

Rates and Insurance Questions

Session Rates and Out of Network Information:

Individual weekly 50-minute sessions: $250 p/session

Extended 75-minute individual/ pre-commitment or pre-marital counseling or marital counseling: $300 p/session

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 FAQ for more information

Medicaid/Medicare recipients: Kindly note that neither you or we are allowed to submit insurance claims for reimbursement. Therefore, you should expect to pay for sessions out-of-pocket.

I've read the session rates and out-of-network insurance information. *

What days are most convenient for you for a consultation? *

Monday Tuesday Wednesday Thursday Friday

What are the best times for you to meet? *

9:30 AM to 12:00 PM 12:00 PM to 2:00 PM 2:00 PM to 5:00 PM (Fridays not available for this option)

How did you find us? *

Would you like to provide any additional information?

We want to support you and do so through a bi-weekly email. Your information is never shared and we don't spam. Ever. Would you like us to include you? *

Yes, I would like to opt-in to your email list and can unsubscribe at any time if it is not for me. No, but thanks for offering to keep me in the loop.

Request Your 20- Minute Complimentary Consultation Here