Let's get started!  Please read carefully before completing the form.
THANK YOU for your interest in connecting with WomenMix Community.

Please note, that we are currently providing virtual psychotherapy for residents of New York City and Florida over the age of 18. 

If you have any questions, please don't hesitate to complete this form or email Jessica at info@womenmixcommunity.com. 

We look forward to connecting with you!

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Email *
First Name
 *
Last Name *
Phone Number *
What service (s) are you interested in? *
Required
How did you hear about us? *
What motivated you to start therapy? *
Have you had psychotherapy in the past? *
Do you reside in the State of New York and are currently located at that state? *
Do you reside in the State of Florida and are currently located at that state? *
What is your availability? *
What health insurance do you have?   *
If you do not have the insurances listed above, session rates are $165 per session. Are you ready to invest in yourself? *
Required
Who is your preferred therapist? (select one) *
If you have or suspect that you have a medical/mental health problem or condition, please contact a qualified health care professional immediately.  If you are located in the United States and are experiencing a medical/mental health emergency, please call 911 or call for appropriate medical help.
A copy of your responses will be emailed to the address you provided.
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