JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
We are glad you found us. Let us know how we can help and we will call you as soon as possible- usually the same/next business day.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name
Your answer
Phone number
Your answer
Briefly tell us why you are looking for therapy now
Your answer
Insurance-We are in network with some policies and work with many through out of network benefits. Which insurance are you interested in using?
Northwell Direct
NYCE PPO (Formerly GHI)
Magnacare
Compsych
NYSHIP/ Empire Plan
HIP
United
Oxford
UMR
Cigna
Aetna
BCBS/ Anthem
None/Self-Pay
Other:
Clear selection
Do you have a preference for therapists?
Your answer
What type of therapy are you looking for?
Individual
Group
Couples
Family
EMDR
DBT
CBT
How did you hear about us?
Google
Social Media (Facebook, instagram, linked-in)
Friend/Family Member
OBGYN
Midwifery
Pediatrician
Other Provider
Psychology Today
Stony Brook Midwives
Brooklyn Parent Support
Life Cycle Psychiatry
Northwell Fertility
Northwell EAP/ Concierge
Postpartum Resource Center of NY
Postpartum Support International
EMDRIA Website
Other:
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Helping Hands Psychotherapy, LCSW, P.C..
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report